Bronwyn Hockersmith writes her notes after meeting with a client remotely, May 4, 2020, in her garage, which is usually her partner Scott’s photo studio. Photo by Philip B. Poston/Sentinel Colorado

There’s a natural silence that can be really helpful in a therapy session. It can be a moment for a client to work through a thought or a cue for the counselor to dig a little deeper, but those lulls can be harder to find in a new era where video-chatting and telemedicine are supreme.

“Witnessing body language and experiencing somebody through space doesn’t really lend itself organically to telehealth, but that’s where we are,” said Bronwyn Hockersmith, an Aurora-area therapist, who operates her own counseling practice.

It’s where a lot of health care providers — mental health and physical health — are these days amid the COVID-19 pandemic that’s forced social distancing measures. While their specialties are different, telehealth prompts similar challenges for professionals across the industry, from small practices like Hockersmith’s to large health networks.

Some difficulties come in the infrastructure, or lack thereof, while other challenges are in the realm of the work itself.

The technological transition wasn’t difficult for Hockersmith. She carries a caseload of about 18 clients per week. “They’ve been really flexible and great,” she said. But for a therapist who specializes in somatic therapy, which focuses on the physical effects of mental health disorders, the current virtual reality can be exhausting.

“I’m a lot more fatigued during sessions,” Hockersmith said. “It (virtual sessions) lends itself to be more work on the therapist’s side because things are not naturally flowing.”

Hockersmith said she plans to return to in-person sessions eventually, when it’s safe. But for other areas of medicine, telehealth is the way of the future and it’s here to stay.

A patient sits in the living room of her apartment in the Brooklyn borough of New York during a telemedicine video conference with Dr. Deborah Mulligan. Telemedicine often involves diagnosing and treating a new health problem but is also used to keep tabs on an existing, long-term condition. (AP Photo/Mark Lennihan)

Years of progress done in days

Physical health care providers had to make the pivot to telehealth rapidly as offices closed and non-emergency medical personnel were asked to hand off their much-needed equipment to hospitals and first responders.

Children’s Hospital Colorado was able to make the shift in about 48 hours. Dr. Alison Brent, an emergency room physician at the north Aurora facility, said the hospital was able to convert about 85 percent of its previous outpatient visits to telehealth within a few days.

The numbers are even more astonishing when put this way: Before the COVID-19 pandemic, Children’s Hospital Colorado was supporting about 100 telehealth visits per week. Now, staff are surpassing 5,000 telehealth appointments per week. Staff at the hospital say infrastructure teams were able to do about five years of work in about five days to attain that reach.

It’s a move that makes sense and is likely to continue well into the future.

“The parents of patients we see are mostly millennials and I’ve never known a millennial without a device to their ear,” Brent said. “We hope this really is a whole new world ahead of us. Telemedicine is just good medicine. That is the foundation. We can meet patients and families where they are.”

Net gains and losses

The shift to telemedicne, which many see as the future, hasn’t been all rosey, however. Many health care facilities across the country have experienced financial hardship because of fewer visits, fewer elective surgeries and, ultimately, lower insurance reimbursements.

There’s also just the lack of technological infrastructure. It’s a problem doctors and health care providers across the country are experiencing.

Dr. Christopher Adams, a rheumatologist at East Alabama Medical Center in Lee County told the Associated Press that infrastructure needed for a workable, widely adopted telemedicine system “simply did not exist” across the region prior to COVID-19, and so the transition hasn’t been easy.

“From my personal experience, we tried two different ways of doing it before our medical center IT department said to heck with it, we’re going to contract this out to a third party,” he said.

And yet, most of his telemedicine visits still take place via phone call instead of video call. Internet access remains spotty or nonexistent in parts of the state, and many people don’t have access to a laptop or phone with a camera.

“I practice in a somewhat rural area, as do many other doctors,” Adams said. “So half of my patients are university types and have the technology. The other half are out driving tractors, or welding, or in construction. These patients often don’t have a video capability.”

That experience hasn’t been limited to predominantly rural states. Colorado has long struggled with a digital divide between the Denver metroplex and outer regions of the state.

In December the state adopted Colorado’s Health IT Roadmap, which lays out 16 initiatives to improve the state’s health care systems. Rural centers have been made a primary goal in many of the initiatives. More than urban providers, they lack affordable and accessible technology.

“Colorado has already made significant inroads into providing remote access to care through telehealth services. But, broadband access required for telehealth is limited, or non-existent, in many of Colorado’s rural communities. The lack of access severely inhibits effective participation in telehealth and access to other emerging capabilities. In Colorado’s rural areas, only 7 in 10 people have access to broadband,” according to the roadmap.

Back in urban areas, where internet access is abundant, Dr. Anne Garrett-Mills, chief medical officer at Aurora Mental Health Center, said her organization and others like it are struggling to find solutions for patients who don’t have access to the technology needed to conduct telehealth services.

Some of Garrett-Mills’ patients are still using flip phones the federal government offered low-income Americans in the early 2000s, she said. They don’t have video-capable computers or tablets, so many “virtual visits” are phone calls.

Garrett-Mills said she’d like to see a type of program like the one that provided cell phones provide tablets so more people could use telehealth services.

Access is also difficult for Aurora’s homeless population that utilizes the Aurora Mental Health services. Health care workers can take iPads to those patients wherever they may be or they can use tech-equipped hubs in the community that allow a person to connect with a mental health professional and still maintain social distancing.

New directions, old bureaucracies

For patients, the transition to telehealth hasn’t been seamless, either. Hiccups with insurance billing still exist, even as virtual doctors visits have been on the rise over the last several years.

Policymakers and insurers across the country say they are eliminating copayments, deductibles and other barriers to telemedicine for patients confined at home who need a doctor for any reason.

“We are encouraging people to use telemedicine,” New York Gov. Andrew Cuomo said last month after ordering insurers to eliminate copays, typically collected at the time of a doctor visit, for telehealth visits.

But in a fragmented health system — which encompasses dozens of insurers, 50 state regulators and thousands of independent doctor practices the shift to cost-free telemedicine for patients is going far less smoothly than the speeches and press releases suggest. In some cases, doctors are billing for telephone calls that used to be free.

Patients say doctors and insurers are charging them upfront for video appointments and phone calls, not just copays but sometimes the entire cost of the visit, even if it’s covered by insurance.

Despite what politicians have promised, insurers said they were not able to immediately eliminate telehealth copays for millions of members who carry their cards but receive coverage through self-insured employers. Executives at telehealth organizations say insurers have been slow to update their software and policies.

“A lot of the insurers who said that they’re not going to charge copayments for telemedicine ― they haven’t implemented that,” said George Favvas, CEO of Circle Medical, a San Francisco company that delivers family medicine and other primary care via livestream. “That’s starting to hit us right now.”

One problem is that insurers have waived copays and other telehealth cost sharing for in-network doctors only. Another is that Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare and other carriers promoting telehealth have little power to change telemedicine benefits for self-insured employers whose claims they process.

Such plans cover more than 100 million Americans — more than the number of beneficiaries covered by the Medicare program for seniors or by Medicaid for low-income families. All four insurance giants say improved telehealth benefits don’t necessarily apply to such coverage. Nor can governors or state insurance regulators force those plans, which are regulated federally, to upgrade telehealth coverage.

“Many employer plans are eliminating cost sharing” now that federal regulators have eased the rules for certain kinds of plans to improve telehealth benefits, said Brian Marcotte, CEO of the Business Group on Health, a coalition of very large, mostly self-insured employers.

For many doctors, business and billings have plunged because of the coronavirus shutdown. New rules notwithstanding, many practices may be eager to collect telehealth revenue immediately from patients rather than wait for insurance companies to pay, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

“A lot of providers may not have agreements in place with the plans that they work with to deliver services via telemedicine,” she said. “So these providers are protecting themselves upfront by either asking for full payment or by getting the copayment.”

Avoiding those hangups has been a bipartisan effort in the Colorado legislature.

In 2016, Colorado lawmakers enacted a measure that requires insurance companies to reimburse health care providers when they offer telehealth services in all 64 counties. Previous law only mandated insurance companies do that in counties with populations of more than 150,000 people.

Dr. Megan Mahoney, center, examines patient Consuelo Castaneda, right, as medical scribe Anu Tirapasur documents the visit at the Stanford Family Medicine office in Stanford, Calif. Some patients are dropping their family doctor as other choices like telemedicine, walk-in clinics and free health screenings at work grow. But health care experts say the fragmented nature of care is precisely why people still need someone who looks out for their overall health. (AP Photo/Jeff Chiu)

Facing the future

While telemedicine and virtual doctor visits have become a necessity amid the COVID-19 pandemic and will likely stick around long after the virus does, there will always be a place for in-person appointments, said Dr. Alison Brent from Children’s Hospital Colorado.

“Medicine will never be practiced the same way again, but I don’t think in-person visits will ever go away,” she said. “An orthopedist needs to feel your bones and a cardiologist will need to hear your heart. Telehealth will never replace in-person visits, but it can augment them.”

Brent highlighted that pairing in-person and telehealth medicine can prevent fragmented care, give doctors a glimpse into their patients’ lives and, in the case of pediatric medicine, allow time for important conversations with parents about vaccinations and other important health questions.

— Kaiser Health News and the Associated Press contributed to this report