Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
Next Time Take Time To Consult Doctors On Telehealth
As a cardiologist and pediatrician at the University of Mississippi, I take issue with your article about telemedicine (“Telehealth Will Be Free, No Copays, They Said. But Angry Patients Are Getting Billed,” April 27). Describing the care sessions as “phone chats,” as the headline on the companion NPR article did, substantially misrepresents what we do. Why did the article get published without the point of view of a single physician? The nature of this complaint boils down to this — I would never try to ask you to write journal articles for me, for free. We, in medicine, ask the same of you. If all phone consultations with physicians were free, we would never have time to see patients in the office. I urge you to write follow-up articles with a more balanced set of sources and realize how your article can now be used as ammunition to further constrain the way doctors practice. It is appropriate to remind readers to check their insurance coverage before they agree to a telephone consultation. It is not appropriate to then also call for free telephone or telehealth consultations.
― Dr. Frank Han, Jackson, Mississippi
Risk of exposure vs risk of accruing high copay and then not being able to pay another bill in this economy. What an unacceptable dilemma
— Mukta Baweja, MD (@muktabaweja) May 4, 2020
— Dr. Yasmin Brahmbhatt, Philadelphia (responding to Dr. Mukta Baweja, New York City)
The article on telehealth was misleading and does the public a disservice by suggesting that physicians are approaching telehealth simply to increase their incomes.
Telehealth allows us physicians to see our patients and help them during a time of physical distancing. We are doing this not because it is “lucrative,” but to serve our communities, to do our jobs, and to take care of our patients while keeping them and our staff safe and healthy.
My practice revenue is down 85%. We have had a drastic reduction in patient visits, and I have already furloughed four of my 10 employees. These calls are far from lucrative, but, yes, they do help us keep the doors open.
Many other professionals charge for their time. After seeing patients throughout the day, we spend hours returning phone calls in the evening. These calls are not reimbursed; and frankly, they should be.
Phone calls and telehealth visits are not “chats.” They are medical consultations. You call your doctor for professional advice and guidance. You call your mother or your friends for a chat.
―Dr. Rachel Schreiber, Rockville, Maryland
— Peter Borden (@peter_borden) April 27, 2020
— Peter Borden, Boston
Jay Hancock’s story on telephone visits did not speak to physicians. Physicians should have been charging for telephone visits in the past (if the sessions met the criteria: initiated by the patient, not related to office visits or results from an office visit, or did not lead to an office visit), but reimbursement was only $14 per call. And many times the telephone calls did not meet billing criteria. However, with shelter-in-place laws and the pandemic, medical care has drastically changed. Patients don’t want to come to the office. They are thrilled to have telephone visits instead. Physicians are doing exponentially more of these telephone visits that meet billing criteria. Office visits have drastically decreased. The Centers for Medicare & Medicaid Services has changed reimbursement for telephone visits to be the same as for video visits, retroactive to March. Charging for telephone visits will help keep doctors’ offices financially afloat so medical care is available for patients in the future. This story is missing the perspective of physicians and also patients who are very happy with the telephone visits.
— Dr. Catherine Nelson, San Mateo, California
I am writing on behalf of the American Academy of Dermatology, which represents more than 20,000 dermatologists and their patients. All physicians, including dermatologists, are committed to providing the highest-quality patient care and have worked to safely offer care throughout the pandemic.
Your recent article correctly outlines how patients are utilizing telehealth to continue receiving care during the pandemic and describes discrepancies in how they’re being billed. While your article addresses these discrepancies in telehealth billing, it does not fully represent the significant challenges faced by patients, physicians and insurers as the health care system shifted abruptly in response to the pandemic.
Physicians are facing significant challenges including:
- Lack of consistency. Many of the current telemedicine insurance policies are inconsistent and include differing reporting and delivery requirements, which creates a significant burden on practices and may delay the delivery of care.
- Confusion surrounding reimbursement. Reimbursement levels and patient cost sharing for telemedicine visits vary across insurers. Many are following CMS and reimbursing in parity and eliminating patient responsibility while others are maintaining that patients must meet their standard obligations. This disparity has many practices collecting a deductible and refunding the patient’s deductible or copayment once the claim is processed appropriately.
- Opportunity to work together. During this time of uncertainty, insurers and physicians are coming together to maintain continuity of care for patients. With any new process, challenges remain. Finding ways to harmonize the disparate requirements physicians are facing is paramount.
Our hope is that you will find this information helpful in providing a full picture of the medical profession’s intense obligation to keep Americans safe during the pandemic while administering quality care.
— Dr. Bruce H. Thiers, president of the American Academy of Dermatology, Rosemont, Illinois
We need more efforts like this one to train more mental health professionals to support care team members, and ordinary citizens who have had to deal with the extraordinary. Thank you, University of California! https://t.co/18d4P7PP2l
— Liz Boehm (@LizBoehm) May 1, 2020
— Liz Boehm, Cambridge, Massachusetts
Thank you. The rest of the news leaves me numb, but I finally wept at all the loss around us and could emotionally process what is actually happening….thanks to this deeply human series.
— Rachel Kauder Nalebuff (@rachelkauder) April 16, 2020
— Rachel Kauser Nalebuff, Brooklyn, New York
Privy To Details About Community Spread
Regarding your series “Lost on the Frontline,” one critical topic was overlooked: fecal transmission and “contact tracing” of toilets. Though the Centers for Disease Control and Prevention says nothing about a fecal vector on its website, Chinese and U.S. researchers have been publishing their data on the coronavirus and feces for months. Toilet facilities for exclusive use by staff could be an overlooked vector that is tragically spreading this pathogen among health care workers.
An asymptomatic patient passes contaminated bowel movements for up to a week prior to feeling ill. Decades of research on uncovered flush toilets have shown their aerosol plume spreads bacterial and viral pathogens in a wide arc. Any location with a communal-use restroom has an inadvertent COVID-19 warehouse/distribution center (if it has been used by an infected person). The CDC can’t say, with any certainty, how long the coronavirus survives on various surfaces and whether it is infectious.
“Contact tracing” must consider which toilets were used by people who tested positive for COVID-19 during the preceding seven days. And then who used those facilities after the contaminated individuals. This flushed-toilet hypothesis, if valid, could explain cluster outbreaks in “contained” settings with designated staff toilets, e.g., ICUs, hospital admitting/triage departments, police precinct stations, corporate conference gatherings, restaurants, etc.
It might help to reflect on the CDC’s befuddlement at the Legionnaires’ disease outbreak in Philadelphia July 1976. Though the pathogen was a simple bacterium and the cohort of ill persons relatively contained and traceable, the agency’s epidemiologists and public health investigators were scratching their perplexed heads until a second outbreak in April 1977 enlightened them.
Getting beyond “respiratory droplets” may take even longer. This pandemic started as a gastrointestinal virus in the Wuhan market. The Coral Princess outbreak has recently been traced to an infected food worker. Until some bright epidemiologist redirects serious attention to fecal transmission and toilets, health care workers will continue to be at high risk of exposure to this deadly virus.
— Tom Heusel, retired registered nurse, Eugene, Oregon
1/2 Every crisis, from wars to 9/11 to #COVID19, begs the question of whether tracking for the greater good is worth more than the concerns it creates. Now that #data & #tracking #technology is so much more powerful, the question is more thorny than ever. https://t.co/xDmxh9pIbw
— Dr. Christopher Chen (@DrChrisChen) April 20, 2020
— Dr. Christopher Chen, Miami
The Nuts And Bolts Of COVID Care
Your recent piece (“As Ventilators Become Crucial In Saving Lives, Repair Roadblocks Remain,” April 17) highlights an important and pressing issue.
As the COVID-19 pandemic puts unprecedented strain on our health care system, it is essential that we ensure medical devices are working safely and effectively. While third-party servicers play a crucial role in the post-market maintenance ecosystem, the fact is many operate in a regulatory “wild West.” In most cases, federal regulators do not even know about specific maintenance companies much less what their qualifications may or may not be. A 2018 Food and Drug Administration report estimated that the “total number of firms performing medical device servicing in the U.S. is between 16,520 and 20,830.” In other words, we do not even have a clear sense of the number of third-party servicers who work closely with medical equipment — a troubling reality, to say the least.
Non-manufacturer third-party servicers do not have to register with the FDA and are not held to the same quality, safety and regulatory requirements as original equipment manufacturer (OEM) servicers.
It is also important to remember that not all “right-to-repair” products are the same. If a repair goes awry with a mobile phone, at worst it may need to be replaced entirely. But the consequences of an improperly repaired medical device such as an MRI machine or ventilator can bring life-altering risks. That is why the FDA holds OEMs to specific quality and safety requirements and why we have advocated that, at a minimum, the agency should:
- Know which third-party services are performing maintenance work
- Assure all technicians are properly trained
- Assure qualified parts are always used
- Require detailed service records are maintained
- Require applicable safety issues or events to be reported to the manufacturer in a timely manner.
It is unfortunate that some third-party servicers have chosen to use the COVID-19 pandemic to alarm the public and advance their business agenda. Instead of pushing for more unregulated servicing, they should register with the FDA, adopt quality management systems, and develop a mechanism for reporting adverse events.
— Patrick Hope, executive director of the Medical Imaging and Technology Alliance
It’s beyond absurd that having enough ventilators is literally a question of life and death…there are ventilators in storage we could repair…and some manufacturers won’t share service information.
— Pat Kelly-Fischer (@PatKellyCO) April 21, 2020
— Pat Kelly-Fischer, Denver
An Insurer Far From Interested In Bailout Money
Julie Appleby and Steven Findlay’s April 28 story, “Health Insurers Prosper As COVID-19 Deflates Demand For Elective Treatments,” implies that all health insurers are looking for a government bailout asking, “So why is the industry looking to Congress for help?” Not true. UnitedHealth Group, which includes UnitedHealthcare and Optum, will not request or accept any government relief money. Instead, we are focused on leveraging the full strength of our resources to support the health and safety of the people and communities we serve.
We are flexing our financial resources, clinical expertise and national reach in dozens of ways to help address society’s most critical needs. We’ve broadened health care access for patients by waiving cost sharing for COVID-19 testing and treatment, reduced prior authorizations, enabled and encouraged the use of free telehealth, offered early prescriptions refills, donated an initial $70 million to COVID-related causes, and delivered nearly $2 billion in accelerated payments to help care providers during a challenging financial time.
The 325,000 people of UnitedHealth Group are committed to doing as much as we can for the people and communities we are honored to serve during this difficult time.
― Kirsten Gorsuch, chief communications officer for UnitedHealthcare, Minnetonka, Minnesota
“Health Insurers Prosper As #COVID19 Deflates Demand For Elective Treatments”
— Ed Mariano, MD (@EMARIANOMD) April 29, 2020
— Dr. Ed Mariano, Palo Alto, California
A Need To Expose Negligence?
Thank you for your exposé on assisted living facilities in the face of the COVID-19 pandemic (“COVID-19 Crisis Threatens Beleaguered Assisted Living Industry,” April 9). My comments are regarding what is missing from the article. Welltower Inc. is the largest player in the industry and it is not mentioned. Ventas, the second-largest player, is not mentioned either. The fact that neither the states nor the federal government took steps when they found how inferior the care was received no analysis.
And, finally, the federal law ― the REIT Investment Diversification and Empowerment Act — that empowers these Real Estate Investment Trusts (REITs) to be so careless with their residents is at the core of the maltreatment of the elderly. No one is addressing the RIDEA Act of 2007.
I have a lawsuit based on the alleged negligence of my mother in Sunrise of Stamford in Connecticut, and my legal team argued that although Welltower was “just a holding company,” under RIDEA it too had liability since it shared in the profits of the operating company. My point is that so much of this industry is ignored. I am fighting for someone to go deeper than the obvious.
― Ted Schachter, founder of Alzheimer’s Defense Fund, New York City
>800,000 are in Assisted Living nationwide, a dangerous theater in the #Coronavirus war. Financial losses, sicker residents, limited oversight, too few employees, may force some centers into bankruptcy & put frail seniors at greater-than-ever risk.https://t.co/YOAKkve2Xm
— C. Michael Gibson MD (@CMichaelGibson) April 9, 2020
— Dr. C. Michael Gibson, Boston