Prior to March and the COVID-19 outbreak in Alabama, Dr. Beverly Jordan’s medical practice in Enterprise did not conduct online telemedicine visits with patients.

But in a recent week, Professional Medical Associates conducted 30 remote visits with patients who either suspected they had COVID-19 or have pre-existing conditions and were trying to avoid the virus by staying home.

“This outbreak has clearly pushed telemedicine in this state,” Jordan told Alabama Daily News.

Dr. Eric Wallace, the medical director for telehealth at UAB, has been working to create a statewide telehealth network in Alabama. He said the conversation has altered dramatically because of the coronavirus.

“It’s changed from a patient willingness to do telehealth, from a provider willingness to do telehealth, from a payer willingness to do telehealth,” Wallace said. “Now we have a real imperative that we have to deliver health care this way.”

Wallace said that with a cell phone camera and a good connection, a physical examination can be done, but telehealth visits aren’t yet a complete replacement for in-person appointments.

“Telehealth is not about getting 100% of our visits remotely; it’s about getting as many visits as possible remotely to prevent the spread while making sure that the people who need care and need it here in person have that option,” he said.

Jordan said her practice previously didn’t do online patient visits for a few reasons, including a lack of coverage by insurance providers and the cost of online services that host the visits in HIPPA-compliant platforms. Before they make the investment, they need to know they have a willing pool of patients to participate, Jordan said.

In March, the federal Centers for Medicare and Medicaid Services said that video and chat apps that don’t normally comply with HIPPA regulations could be used during the COVID-19 public health emergency.

Then platform providers started offering free 30-day trials of their products. That’s how telemedicine came to Jordan’s office.

“I don’t think it’s going away,” said Jordan, a member of the Alabama Medical Association Board of Censors.

‘Not as simple as it seems’

Telemedicine was in Alabama before COVID-19. Each Alabama Department of Public Health county office has the capabilities to connect patients with some providers in other parts of the state, but that still requires patients to leave their homes.

Particularly in rural communities, telehealth has not been widely used.

Jordan estimates that about two-thirds of her patients don’t have a device that has the video and audio capabilities required for telemedicine, or they don’t have adequate internet access.

“It’s not as simple as it seems if you don’t have the technology,” Jordan said.

Alabama’s broadband access issues are well documented. A map published earlier this year from the Alabama Department of Economic and Community Affairs showed nearly half the state without high-speed internet access.

“It’s something we knew, but it has been made clear: There is a whole group of people who don’t have access to services simply because of where they live,” Jordan said.

Wallace also acknowledges that access is an issue.

“One of the things we don’t want to do is increase disparities in care,” he said.

Those without capable devices may have a relative who can provide access, Wallace said.

There’s also a learning curve. When Jordan’s practice decided to offer online visits last month, doctors and staff pooled every smart phone they could find in order to troubleshoot potential problems patients may have, from finding the compatible browser to turning on camera capabilities.

“It’s taking a nurse with a teacher’s heart to call all these patients to walk them through everything,” Jordan said.

Insurance

Of the 30 virtual appointments in a recent week, Jordan said none of them would have been covered by patients’ insurance prior to COVID-19.

“No one can continue to do this if insurers don’t pay for it,” she said.

Last month, in response to the virus, Blue Cross and Blue Shield of Alabama, the state’s largest insurer, expanded its coverage of telehealth services.

“Our rapid and broad expansion of telehealth has been due to, and limited to, the COVID-19 crisis,” said Koko Mackin, vice president of corporate communications for BCBS of Alabama. “We will be looking at month-by-month extensions as needed.

“We do hope the lessons we learn from this initiative will allow us to thoughtfully develop more permanent solutions that will benefit our members having access to high quality and cost-effective care using a telehealth platform.  We also believe this will benefit our in-network providers by providing them with another means to care for their patients.”

Wallace at UAB said during the COVID-19 response, there has been great support from insurers willing to pay for telehealth services.

He said that needs to continue “to make sure when COVID goes away, this doesn’t go away.”

Prior to COVID-19, some Alabama lawmakers had been discussing for about a year ways to expand online access to doctors in Alabama. One of the first steps is requiring insurers to cover it, Sen. Dan Roberts, R-Mountain Brook, said recently.

Though the coronavirus has put the legislative session on hold, Roberts late last month filed Senate Bill 323, which would require insurers in Alabama to provide coverage for telemedicine services, including interactive audio or video, for the purpose of diagnosing or treating patients, providing remote patient monitoring services, or consulting with other health care providers regarding a patient’s diagnosis or treatment.

“Telemedicine has gone leap years from where it was a month-and-a-half ago,” Roberts said. “I think this has the opportunity to be a game changer for delivering medicine in our state.”

But questions remain, including whether such a mandate is possible or wise given Alabama’ technological gaps.

“How do we take it further, so we don’t have disparities across our state?” Roberts said.

Possible federal dollars

In his west Alabama district, Sen. Bobby Singleton, R-Greensboro, recently helped his mother connect with her physician at UAB through telemedicine, avoiding a trip to Birmingham.

“We’re seeing (telemedicine) work because of this pandemic,” Singleton said.

Still, the infrastructure needs are significant.

“Many of our hospitals, specifically in rural areas, don’t have the basic funding even to get one of these (telehealth) programs up and running,” Wallace, the UAB doctor, said.

Singleton approached the Alabama SuperComputer Authority earlier this year about possible federal money to launch a pilot program at about 15 sites around the state.

The Federal Communication Commission’s Rural Health Care Program provides 50% to 60% funding to eligible health care providers for telecommunications and broadband services. The SuperComputer Authority was going to apply for the grant money this year, but Walter Overby, its chief executive officer, this week said it would likely delay applying another year. That’s because the federal CARES Act, approved by Congress and signed by the president last month, includes about $200 million for telehealth infrastructure for nonprofit and public providers. If they can get a portion of that money, it would be a better deal for providers than the originally proposed grants, Overby said.

“Some of these places are on very tight budgets,” Overby said.

The Alabama Supercomputer Authority is a state-funded corporation charged with developing and operating a statewide supercomputer and related telecommunication systems.

“We’re trying to get this program up and running that would allow us to connect to more sites so telemedicine can be done,” Overby said.

Sen. Arthur Orr, R-Decatur, has advocated for telemedicine expansion and earlier this month said some state dollars for federal matching grant dollars could be included in the 2021 education budget.

While the coronavirus has highlighted the need for more telemedicine in Alabama, work on this funding started before the virus, he said.

“We need to move as a state, we need to push this out as best we can as quickly can,” Orr said.