There has been a bright spotlight on the importance of the future of telehealth throughout the COVID-19 pandemic, and last fall, hundreds of health organizations sent an open letter to the nation’s state governors, pleading with them to maintain cross-state licensure and telehealth flexibilities as the U.S. response to the COVID-19 pandemic continues to evolve. The prominent signatories ranged from key healthcare provider groups to technology and information management groups to public advocacy organizations, united over the benefits of telehealth for the treatment of pain.
According to an American Medical Association (AMA) survey, use of telehealth platforms soared from 25 percent in 2018 to almost 80 percent in 2020, driven by the pandemic. And indeed, for many people struggling with acute and chronic pain and their clinicians, telehealth has been a godsend, linking vulnerable, underserved patients with equitable, accessible care during a period of stress on the care system. Pain management is a complex practice for pain specialists and physician anesthesiologists and one that intuitively seems to require a face-to-face interaction to improve health outcomes. It is, of course, challenging to assess pain level with telehealth alone, but paired with an office visit the possibility provides hope for patients to gain access to specialist care.
The need for telehealth services for patients with chronic pain became clear during the COVID-19 pandemic. A U.S. Pain Foundation survey conducted at the peak onset of the pandemic in April 2020 found that 63% of patients were experiencing increased pain, and 77% were experiencing barriers to medical care. A research study published by the Journal of Interprofessional Education and Practice in 2022 found that there was statistical significance among the 98 healthcare professionals’ ability to aid in pain and opioid management with telehealth. Both patients and physicians adapted to the new telehealth model through the emergence of remote technologies: video conferencing, electronic stethoscopes, wearables to track symptoms, and intuitive pain benchmarking and reporting apps; increased use of intrathecal pump refills and other alternatives for pain therapy; and transition to home-based “self-collection” of drug monitoring test samples in conjunction with telehealth sessions.
Going forward, stakeholders including policymakers and physicians must intentionally pursue opportunities to further use the future promise of telehealth in pain management -- or risk its stagnation. A focus on equitable access, coverage and continued innovation will bolster the case for the former, potentially transforming the future of pain management and treatment guidelines well beyond the pandemic. There are several key steps to improve telehealth access focused on patient-centric care:
First, policymakers and practice managers must protect equitable access for patients and physicians. The transformational adjustments during the pandemic literally pivoted pain management toward a true patient-centric care model. As policymakers look to restore a balance between in-person and telehealth care, they cannot backtrack on these successes, maintaining every and all avenues to link patients with care. And they must further build these innovative tools and infrastructure to address issues like cultural and linguistic differences, digital literacy, and access to reliable data and internet, so that telehealth does not widen existing health inequities.
Second, policymakers must ensure ongoing equitable access, reimbursement and insurance coverage. To address healthcare continuity during the COVID-19 pandemic, a series of regulatory actions, including the Coronavirus Preparedness and Response Supplemental Appropriations Act and 1135 waiver authority, allowed the Centers for Medicare and Medicaid Services (CMS) to expand telehealth by authorizing Medicare payments at the same rate as in-person visits for certain services, including services for pain management. The U.S. Department of Health and Human Services also permitted health care providers to safely prescribe pain medications and appropriate opioids via telehealth. Going forward, insurances and payers should maintain access and reimbursement for telehealth services, in particular for mobility-and health-compromised individuals. Healthcare professionals and care providers must be able to refer across specialties, including telebehavioral health, with the expectation that those services can also be provided remotely. In order to create equitable access, patient out-of-pocket copays or costs related to telehealth visits, when applicable, should never exceed the in-person rate.
Third, there are many innovative developments in the pain management field – and to realize the potential of patient outcome improvements, stakeholders must embrace innovation in both medical practice and insurance coverage. New approaches like neurostimulation and spinal cord stimulation may play an increasing role in managing both acute and chronic pain. These innovative, implantable devices transmit electrical impulses that inhibit pain signals before they reach the brain, considered a non-opioid alternative. Yet reimbursement for the use and follow up use of these devices often require an in-office visit which could easily be handled through telehealth.
A recent survey from digital testing solution company Applause found 63% of respondents who used telehealth plan to increase that use after the pandemic ends. Patients with pain already suffer tremendous barriers to skilled, compassionate, holistic care. Policymakers and other stakeholders can help to bridge that gap by advocating for increased access, appropriate coverage and advancing innovation for the future of patient-centric telehealth.
Dr. Leong is the Director of Neuromodulation and a Clinical Professor at the Stanford Pain Management Center and has no conflicts of interest to report. Dr. Gupta is adjunct assistant professor in Johns Hopkins School of Medicine Department of Anesthesiology and Critical Care, FDA advisor, National Academies of Sciences Global Forum member and an appointed expert member of the World Economic Forum for the future of health, biotechnology and pandemic preparedness. Dr. Gupta has no conflicts of interest to report.
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