Telehealth has been layering into healthcare delivery for the past decade. Large-scale adoption has been slow and steady until recently; implementing telehealth truly exploded during the COVID-19 pandemic. Across the healthcare industry, telehealth use increased 38 times the pre-pandemic levels. It now accounts for about 13-17% of all office and outpatient visits across specialties, including OB/GYN, according to a report by McKinsey. Before the pandemic, one analysis put pregnancy-related claims delivered by telemedicine at just 0.1%.
OB/GYNs now have myriad ways to connect with their patients, including messaging via text or web portals, wearables, mobile health apps, video appointments and at-home monitoring systems. Telehealth prenatal care also expanded as pregnant patients faced risks from COVID-19. In light of the continued closures of rural hospitals, the need for effective telemedicine still exists and requires commitments from insurers and government to maintain access to the equipment and technology needed.
Using Telehealth in Obstetrics Care
The appeal of implementing telehealth is to improve access and cut costs, particularly in the U.S., where many areas are experiencing an increase in maternal mortality. People living in rural areas have a 9% higher risk of severe maternal morbidity or mortality compared to people in urban areas, according to the Kaiser Family Foundation (KFF). Telemedicine for prenatal and postnatal care, as well as mental health care surrounding pregnancy, has been highly recommended by the American College of Obstetrics and Gynecology among others — but uptake before the pandemic was slow.
Frequent office visits during pregnancy can be challenging for patients who don't have reliable transportation or live far from a clinic. KFF recommends a schedule of alternating in-person and virtual visits. A meta-analysis published in Obstetrics and Gynecology found that telehealth interventions were effective for improving obstetric outcomes, smoking cessation, breastfeeding, getting early access to medical abortion and scheduling optimization for high-risk obstetrics.
In addition, using apps to check in with care providers may lead to better adherence to prenatal care appointments and postpartum care recommendations, according to KFF.
Further, rural or underserved areas are less likely to have specialists for high-risk pregnancies; telehealth can allow local providers to consult with specialists far away. For example, in the U.K., a study published in BMC Pregnancy and Childbirth connected the obstetrics unit in a rural area with a fetal medicine specialist. Families attended in-person doctor visits at their local obstetrics unit that also included a video conference with a specialist who could see their ultrasound images in real time. The study found that this setup was effective at diagnosing a fetal anomaly and monitoring the fetus for risks, including gestational age, premature rupture of membranes, twin-to-twin transfusion syndrome and red cell alloimmunization.
Plus, KFF found numerous studies of pregnant patients with gestational diabetes who used telemedicine to monitor their condition. Outcomes were similar between telemedicine and in-person care.
Using telehealth in this way saves patients time and money on travel to a specialist center and reduced unnecessary referrals when the obstetrician had concerns.
Implementing Telehealth in Prenatal Care
During the height of the pandemic, federal and state regulations relaxed to allow for more insurers, including Medicare and Medicaid, to provide payment or reimbursement for telehealth visits. However, many of those regulations have since expired; therefore, there are some considerations healthcare settings of all sizes must take into account if they decide to continue offering telehealth services.
Licensing Requirements
In most states, the doctor must be licensed in the same state where the patient is located. In some cases, the doctor must also be licensed in the facility where the patient will deliver. This can cause some limitations for patients — particularly those who live near state or county lines or those who live long distances from large metro medical centers.
Virtual visits that cross state lines make up a small percentage of total visits, but they occur more often with patients in rural areas. So, addressing licensure can have an impact on obstetrics care in these areas.
Reimbursements and Costs
Medicare added more than 100 telehealth-related billable codes during the pandemic, paid out at the same rate as in-person visits. Before the pandemic, only 19 state Medicaid programs offered reimbursement for telemedicine delivered to patients at home. Coverage still varies and the future of reimbursements during the pandemic is unclear. That's important to the future of prenatal telehealth in the U.S., as Medicaid covers half of births in the country, according to KFF.
Most private insurers now offer some level of telemedicine care for patients. It's important to know which codes are billable to which insurers so healthcare professionals can inform their patients of any financial responsibilities they may have, even in a telehealth setting.
Coverage and reimbursements also lag for telehealth lactation services. The KFF analysis found that some programs accept health savings accounts whereas others offer memberships — but not all programs are covered by insurance.
Workflows and Training
Shifting to offering telemedicine or remote monitoring requires changes in workflow. A study of Mayo Clinic's OB Nest program found a decrease in physician time but an increase in nursing time when connecting virtually with patients throughout their pregnancies. Offices should figure out a balance based on patient needs and staff availability in order to adjust workflows accordingly.
Technology
Both patients and providers need access to the appropriate technology, as well as equipment. Patients need broadband internet, which is still not available in all areas across the country. Healthcare settings also need high-speed connections and the necessary software to transfer private information and images securely.
For at-home monitoring, patients need blood pressure cuffs, fetal monitors and other durable medical equipment. Bundled rates or reimbursements for at-home obstetric monitoring need to account for covering these rentals, as well.
Moving Telehealth Forward
Telehealth options were widely popular during COVID-19 and generally made patients happy. As newer technology comes onto the market and the FemTech apps continue to expand, providers have a growing library of options to choose from when it comes to remotely connecting with and monitoring patients. The trick is going to be finding the best tools and incorporating them into routine practice.
