Telehealth remains popular in Minnesota, does not lower quality of care: MDH report

Dr. Stephen Robinson could see that his patient was weary, that she had more to discuss than the foot pain that prompted her appointment.

"I wake up at 2 and I'm awake until 4," she confided. "I worry about my kids. I worry about what's going on the next day. My mind is spinning."

The mood was different a half hour later, as Robinson smiled while a property manager with a history of anger and anxiety explained how her medications are working and she avoided confrontation with a hostile tenant.

"I could have spiraled," the property manager said.

One of these visits was in-person and the other was remote, but it's getting harder to tell the difference these days beyond the use of technology. The Minnesota Department of Health (MDH) made that point last month in a report that found growing, everyday usage of telehealth in clinics far beyond its origins as a diagnostic tool for garden-variety colds and infections such as pink eye.

"The picture of telehealth is getting clearer," said Pam Mink, the MDH director of health services research. "It's really evolved into a lot of aspects of primary care."

The report said the state Legislature should continue investing in telehealth and encouraging its use after it became a lifeline during the COVID-19 pandemic. Telehealth use increased from 3% of primary care visits among privately insured Minnesotans in 2019 to more than 20% in 2021, the report showed. But even in 2022, when no pandemic restrictions were in place, patients chose it for 19% of those visits.

Online options such as Virtuwell remain available, pairing patients with doctors they likely haven't seen before to make routine diagnoses and issue quick prescriptions. But the post-pandemic growth has largely been among primary care doctors in their visits with established patients, especially those needing regular checkups and medication adjustments for chronic conditions such as diabetes and depression.

At his M Health Fairview primary care clinic in Prior Lake, Robinson toggles between patients he sees virtually and face-to-face. Telehealth has been indispensable since he moved his practice from Andover, he said, because loyal patients don't want to change doctors but also don't want to drive from the north metro to the south for appointments.

"I mean, trying to drive down here at 5 o'clock at night?" he said. "Forget it."

Robinson prescribed a low-dose antidepressant during his in-person visit with the sleepless patient to see if it helped, but stressed to her that "this isn't prison, OK? If we decide in six weeks that this is terrible, or it isn't doing anything, then we'll stop." The second patient visit was online. Robinson ordered prescription refills and scheduled vaccinations for the woman who was reporting stability with her mood and medications.

"I trust, if things go south, you will reach out to me," he told her.

Telehealth has grown especially popular for mental health appointments, but it can address many physical ailments, said Dr. Annie Ideker, an associate medical director who led the post-pandemic expansion of telehealth at HealthPartners clinics and hospitals. On one shift last week, Ideker conducted online sessions with patients who had Parkinson's disease, osteoporosis, anxiety, high blood pressure and acid reflux. She said she has assessed orthopedic issues remotely by having patients demonstrate their range of motion on screen.

"It's two-dimensional, and you're only seeing their face, so you might miss some of the body language, like if they are tapping their foot under the desk or something," she said. "It's just a matter of being aware of that and using other techniques to try to elicit some of what you might be missing."

The state report offered mixed results in terms of the impact of telehealth on quality of care. Patients using telehealth were more likely to do checkups after hospitalizations, which are recommended to address any overlooked or delayed complications that could send patients right back into hospital care.

However, one analysis of elderly Medicare recipients with complex diseases showed that those who used telehealth were more likely to need emergency room or hospital visits. That might say more about the severity of health problems for people who choose telehealth than the quality of care they receive with it.

Mink said it's possible they "are using telehealth in part because their condition is not well-managed and it might already be too late for telehealth visits to help."

Other analyses in the report showed no elevated rate of hospital usage among telehealth users, either for publicly or privately insured Minnesotans, she added.

The state findings could inform an ongoing federal debate. Congress is under time pressure to decide before the end of the year whether to extend federal COVID-era policies that allowed all providers to offer telehealth to Medicare recipients and to pay for telehealth visits at the same rates as in-person visits.

Telehealth didn't inflate health care spending in Minnesota, the study found, but there was no evidence of savings, either. The hope is that telehealth will reduce health care spending by increasing medical checks on chronically ill patients and preventing them from suffering costly and preventable complications. But the timeframe of the report was too narrow to document long-term effects.

Advocates expect that telehealth can plug gaps in care for rural and low-income Minnesotans, and connect primary care doctors remotely with specialists for low-cost recommendations on how to provide intensive care and manage conditions such as strokes.

The state also encouraged investment in audio-only telehealth visits, which can be easier for older and rural patients to access than video visits. Audio visits have limits, though. Mink said they don't work well for group therapy.

Robinson's final patient of the day was playfully surly while sitting in a lawn chair on his deck in Coon Rapids and speaking remotely with his doctor. Jim Block, 74, insisted that he didn't want to go to a cardiologist, even though tests during an ER visit showed he had an unusual heart rhythm. Block then panned his camera across the deck to his wife, Cindy, who was shaking her head. The doctor realized he had an ally in nudging his patient to do what he wanted him to do.

"Jim," he told his patient, "sometimes we have to pacify Cindy."

Block turned the camera back to his face and sighed. He said he would be going to the cardiologist.