COVID Upends Care Connection: Assessing Adjustments in Patient-Doctor Relationship

New digital technologies have long built upon and modified the path for medical development and improved patient care with an eye toward further advancements in the years ahead.

Such high-tech drivers as automation, artificial intelligence, track-and-trace systems, and personal communication devices that became common in industrial applications in recent years increasingly made significant inroads into the medical and pharmaceutical universe.

Then came COVID-19, a pandemic that turned the entire world upside down, immediately reshaping every aspect of life, from how we interact with each other, our families, and doctors, to how we oversee daily business operations.

Now a year into the pandemic and surrounded by continuing questions over the lasting impact of COVID-19 on the general population and the medical community, all sides seem to have accepted—and in some cases welcomed—at least some of the changes brought on by the so-called “new normal” in healthcare.

The real question then becomes, which of the societal changes are here to stay and which others will influence routines to a modified degree, but not alter future procedures.

It also becomes, how has the doctor-patient relationship digested its biggest changes and challenges in so short a period of time, including the almost universal adoption of virtual care; impact on surgical procedures and specialty practices; social distancing and safety requirements; restrictions on family members accompanying patients; telehealth insurance implications; and the impact on drug sampling, diagnostics, and prescriptions.

Emergence of telehealth

Perhaps the biggest change in the doctor-patient relationship over the past year involved the sudden widespread use of virtual care through telehealth technology.

“We look at weekly medical claims divided by office, institutional and telehealth versus a baseline, and what we see is that telehealth barely existed at the beginning of the year, but it was one of the only options in March and April into May,” says Doug Long, vice president, industry relations at IQVIA. “In fact, in the week of April 24, a full 17.1% of all the medical claims were through telehealth, as office and institutional visits really dropped through the floor.”

Although telehealth visits declined substantially since the April pandemic lockdowns, they made significant inroads into healthcare through the end of the year as new waves of COVID-19 infections again swept through the country heading into the fall months.

By the end of 2020, telehealth still represented about
11% of medical claims, but experts are keeping a close eye on whether elective surgeries and similar non-urgent procedures once again become delayed, which could give telehealth another percentage jump.

As for use of virtual technology for types of patient visits, the IQVIA research showed wide variations.

“For conditions such as rheumatoid arthritis and lupus, there have been big increases in telehealth visits, but for ADHD there’s been little use of telehealth, so a lot depends on what the patient is coming in with,” notes Long. “I’m sure that everybody’s looking at what’s the best use of telehealth options.”

While no one seems to be suggesting that telehealth will replace face-to-face consultations or otherwise negatively impact traditional doctor-patient relationships, medical professionals may now see specific ways that increased use of telehealth can actually enhance their patient experiences and relationships going forward, albeit in different ways depending upon the needs of individual medical practices and specialties.

In a critical area like oncology, for example, telehealth can present a huge win for physicians and patients alike from the standpoint of treatment support and access to preferred ancillary care.

“As we put patients through [cancer] treatments, there are so many who have mental health needs,” explains Ellen A. Ronnen, MD, medical oncologist at Regional Cancer Care Associates in East Brunswick, NJ. “Patients are busy, they have a lot of appointments and getting people to mental health experts can be a challenge, especially if it means they have to drive 30 minutes and wait in the waiting room. But mental health via video could be a great solution for a lot of those patients.”

Ronnen would see a similar benefit in genetics counseling through the use of telehealth.

The prevalence of telehealth visits and consultations between patients and physicians have varied widely by condition. (daniilvolkov - stock.adobe.com)

“For us, genetics counseling is important because we’re looking for why a patient might have gotten this disease, are they more susceptible; their family history might be leading you down that road to consider it. But often there are long waits for the geneticist, there aren’t that many genetics counselors, and patients just don’t want to travel. It can be another appointment that will be a three-hour event.”

Conducting a video visit, however, along with consideration of family history and determination of needed testing, the patient might only be required to go in person for the necessary blood work instead—a plus for both doctor and patient.

While Ronnen overall prefers in-person visits, it comes down to patient safety for such a high-risk group. Some patients and family members initially express concern, but accept the addition of telehealth visits once they give it some thought. “I’ll explain to them that bringing them into the office is putting them at risk. They’re on chemotherapy and I’m trying to protect them and we as a practice are trying to protect them in every way that we can, including limiting traffic in the office.” The limits during the pandemic have not affected chemotherapy and other essential treatments, she adds.

Virtual care in surgical applications

While many questions would need to be resolved, it appears that virtual technology may even make beneficial contributions into areas that demand hands-on treatment, such as in surgical environments.

“Patients like it because it’s a convenience for them. They don’t necessarily have to take off a day from work, they can do it from the comfort of their home,” says Ross Goldberg, MD, a general surgeon practicing in Phoenix and current president of the 4,000-member Arizona Medical Association representing the state’s medical and osteopathic physicians. “The question is, there’s a time and a place for it and how do you do that?

“As a surgeon, I have to examine you to figure out if I’m going to operate or not. I’d like to meet you before that happens, so what we’re doing now is we’re trying to figure out where to use [telehealth], where not to use it. We’re all evaluating that now. It’s going to be a fixture after this is all done, we just don’t know what shape and form it’s going to look like just yet, and we’re partnering with insurance companies and the [state] legislature to figure out exactly what that’s all going to look like.”

Casey Korba, research manager at Deloitte Center for Health Solutions, tells Pharm Exec that beyond the actual procedures, “there’s so much that happens before and after that surgery that can be done virtually—the pre-checking, the information exchange that happens between patients and physicians, and what happens after surgery.

“If you’re not having complications, if you’re healing nicely, a virtual visit might be a great option and you might not need to go in,” says Korba. “A lot of specialties that hadn’t thought about those events before and after a procedure might be more interested in the future in scaling those up.”

In addition, some physicians see telehealth as just a start of a move toward greater digitization in medicine to further benefit the overall patient experience going forward.

“One thing that I think can help doctors in the future is what they refer to as a clinically integrated network,” says Carlos Baez, MD, a physician in family practice at Southern California’s Pomona Valley Health Centers, operators of five medical facilities in the particularly COVID hard-hit Greater Los Angeles region, who adds that such a network would significantly cut down on administrative work by physicians.

For example, a clinically integrated network would allow a specialist to be patched into the same network as the primary care provider (PCP) and others so all have real-time access to all patient information.

“I think on many levels it improves the quality of care, it improves the communication; I don’t have to bring the patient back because I don’t have the documents needed in order for me to proceed with what needs to be done,” says Baez. “That’s one thing that is very frustrating that can definitely improve medical care in general and cut down on some of the administrative stuff that goes on behind the scenes just to get information from other people.”

Insurance dilemma

While all of the experts interviewed believe that inclusion of telehealth is here to stay for the longer term, some significant considerations still must be addressed, including the insurance component.

“There’s a question about the right balance and model of payments, so that there’s not just lots and lots of [virtual] visits, but that there’s some rational allocation between the two,” says Sarah Thomas, managing director of Deloitte Center for Health Solutions. “I do think that there’s going to be some new patterns of care that are dreamed up and there’s going to be some thought on how to pay for that in a thoughtful way that continues the access without necessarily creating additional volume.”

From a physician standpoint, there’s also concern over the possible perception that telehealth is less involved, and therefore less costly than office visits.

“There is a misconception that it’s cheaper to do a telemedicine visit,” says Goldberg. “It’s more convenient for the patient but it’s definitely not cheaper. There’s still resources and personnel that go into every visit. Even though you’re not face-to-face, you’re still needing people to room patients virtually, scheduling them, and now you’re talking about the infrastructure to have the appropriate audio or visual equipment to make sure it’s HIPAA compliant, that you’re in a HIPAA space.”

The Arizona Medical Association has been in meetings with the state’s public and private insurance leaders about the issue, according to Goldberg. “It’s been a good discussion actually to understand everyone’s position on this, where we’re coming from, and it has led to some good starting conversations on how we’re going to do it [once Arizona Gov. Doug Ducey’s executive order requiring coverage for telemedicine visits is lifted].”

Contending with connectivity dysfunctions

Although the quality of those doctor-patient interactions varied especially at the outset when systems were, in some cases, cobbled together and took some time for both sides to adjust, as time went on and patients became more familiar with the new telehealth approach, many have learned to accept it as a convenience as well as a measure of safety with the pandemic continuing to rage.

“Initially, when all this started out, telehealth was very new to us all,” explains Pomona Valley’s Baez. “On the patients’ side, connectivity was an issue. I refer to it as ‘connectial dysfunction’ on all levels as patients were a little hesitant, doctors were a little hesitant, and everyone was on a learning curve.”

Despite those early technical hiccups, Baez and other physicians interviewed expressed satisfaction with the benefits of telehealth longer-term for their respective practices beyond the pandemic stages.

(Andrey Popov - stock.adobe.com)

“There is a sense of I’m going to talk to you somehow, I’m going to address your concerns somehow,” says Baez. “I find at this point that patients are very comfortable, that learning curve has improved to the point where there’s very few calls or appointments basically that fall through the cracks because of some technical issue. I think in the long-term as far as the physician-patient relationship is concerned, telehealth is going to have huge benefits, but I still think the majority of patients would prefer to come in and have a face-to-face consultation with the doctor and have that physical examination, which I think is very important in that relationship.”

That said, the medical community and patients have adapted to occasional telehealth issues by employing alternative and less high-tech communications devices when necessary.

“We always want to make sure that everyone has the ability to access what they need to access,” says Goldberg. “Now, not every health visit so far has been video required, you can use some audio. For example, I’ll follow up with a patient to see how they’re doing, how’s their blood pressure, what’s going on; you don’t necessarily need a video, you just need a phone.”

Maintaining distance and patient trust

While telehealth now is widely being recognized as a major tool in helping preserve strong physician relationships, social distancing requirements at times have led to cracks in trust even among long-established patients.

While patients seem to accept the new pandemic requirements that limit the number of people allowed into facilities at a given time, doctors continue to face some blowback over limitations preventing family members from accompanying ailing patients during consultations or even visiting gravely ill patients at hospitals.

It can be heart-wrenching at the most critical times, but even during more routine visits, some patients, spouses, and other family members often express concern and frustration from such limitations.

“They’re concerned, but not to be blunt about it, there’s no choice in the matter,” says Goldberg, who, like many other physicians, has turned to technology as a workaround solution to ease concerns and keep family members involved.

“I’ve had a few patients who can’t have someone with them [in the office] and there are some occasions where you need to have someone with them for a variety of reasons,” he adds. “Their family member will wait in the car and they’ll FaceTime them in so they can at least participate in the conversation that’s occurring. Because almost everyone now has a smartphone, it’s a way they are keeping their family informed even though they can’t physically be there.”

Similarly, Baez has had success using audio and video technology in his family consultations when necessary.

“Someone may be accompanied by a family member and if the person has a cognitive issue, for example, a dementia, or they have some physical disability, I allow the family member in when possible to help them with that and to help me with that as well,” he says, adding that if for some reason that family member remains in the waiting room area or outside in their car, they may have them join in via phone or FaceTime in order to participate.

Baez and Goldberg both point out that allowing family members to participate remotely passes the HIPAA test since the patient agrees to allow it in much the same way he or she would during a typical office consultation.

Beyond the methods and accommodations that individual physicians and clinics are making to ease the strain on patients and families as they navigate through the pandemic, some recent data indicate that additional strategies might be needed to maintain patient trust.

“This larger issue of trust is so important,” says Deloitte’s Korba, who referred to some preliminary results gathered during the unit’s fall consumer survey. “Some of our early data showed that a lot of the health systems were focused on training around privacy and the actual technology, but what we really want to see scale up is more training around communicating in these different platforms, including telehealth, as the healthcare system experience evolves,” she says. “Are physicians and clinicians best prepared to serve patients and continue to earn their trust? That’s what we think health systems should be focusing on in the coming years.”

Pharma impact

Of course, as with most if not all things, every cause has an effect. So, too, with COVID-19, which not only altered medical and healthcare practices almost overnight, it also has had a profound impact on the pharmaceutical sector, ranging from increased focus on vaccine development to the slower introduction of new medications.

“I think there’s still a lot of catching up to do from the pharma perspective,” Deloitte’s Thomas tells Pharm Exec. “I’ve seen data that suggests people had no shortage of drugs they were taking, but there has been a reduction in the number of people starting a new medicine.”

She adds: “Some of the things I’m a little concerned about from a health perspective is that there are some undiagnosed conditions that aren’t getting treated and were missed in the usual course of preventive care. The implication for pharma companies is that some of the medications that people would have been put on, they have not had the benefit of yet, so there’s some catching up.”

For example, an individual who had not yet been diagnosed with hypertension or nascent diabetes when the pandemic began potentially may have fallen through the cracks and not been prescribed medications for those illnesses for several months. “I think that’s more the issue,” says Thomas.

In addition, IQVIA market tracking noted a fairly significant impact on new-to-brand prescriptions (NBRx) for various specialties when comparing face-to-face versus telehealth visits, since telehealth does not generate as many new prescriptions for a visit as an office consultation.

According to IQVIA’s report, “Monitoring the Impact of COVID-19 on the Pharmaceutical Market,” published in December 2020, per-patient visits for the week ending Dec. 4 showed that telehealth generated 18% fewer NBRx by allergists; 20% by dermatologists; 30% by rheumatologists; and 33% by cardiologists. The biggest drop-offs were in psychiatry, down 40%; urology, 43%; and endocrinology, 44%.

IQVIA attributed the potential drivers of the difference to several factors, including willingness to initiate new therapy remotely, lack of diagnostics such as vitals and labs impeding diagnosis of new conditions, and prescribers spending less time on a telehealth call which may reduce NBRx opportunity.

Similarly, when elective surgeries were curtailed for several weeks shortly after the start of the pandemic, the move also affected pharma.

“If you are having elective surgery somewhere, generally there’s some prescriptions generated in connection with elective surgery,” explains Long. “If you’re going to have a dental surgery, there’s usually an antibiotic, anti-swelling, and maybe a pain medication. So, if you’re not doing those, you’re not seeing those prescriptions.”

He pointed out that mammograms were down 90% around the beginning of 2020, and speculated that prostate-specific antigen (PSA)tests were also probably down since patients weren’t traveling out of their houses and telehealth had become a big part of the office visit.

There also has been somewhat of an impact on new product launches since in-person visits from pharmaceutical sales reps were curtailed as physician offices began restricting outside visits at the pandemic outbreak.

“As for the issue of sales reps coming in, it’s more around medications that were launched,” notes Thomas. “I do think we’ve been having some of the conversations with our pharma clients, it’s just been slower than expected. People have had the chance to have virtual interactions that replaced some of the old models, but it hasn’t entirely sprung back in terms of new product launch.”

Fortunately, following initial office shutdowns, pharma seems to have weathered the pipeline disruptions fairly well and expectations are that 2021 will see a return to new drug sampling and introductions.

“I think it’s going to pick up now that we have the vaccine,” says Goldberg. “A lot of things went on hold, like vendors that were put on restrictions at hospitals and physician offices to limit the number of people coming in to be safe.”

He anticipates that drug representative and vendor visits might begin to come back, possibly by mid-year, as the COVID-19 vaccines get more widely distributed.

“The only new thing is the vaccine at the moment, which we’re all pretty happy with, so it’s a start.”

Mike Botta is a freelance journalist based in Greater Phoenix, Arizona