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远程医疗蓬勃发展,美国州内医院危机四伏

远程医疗蓬勃发展,美国州内医院危机四伏

Matt Volz, Kaiser Health News 2021年03月27日
新冠疫情爆发一年来,远程医疗已经得到广泛认可,但一些意想不到的后果也随之而来。

哈泽尔登·贝蒂·福特基金会(Hazelden Betty Ford Foundation)于今年2月初开始在蒙大拿州提供远程医疗服务,这家美国最大的非营利成瘾戒断机构承诺,偏远地区的居民在家也能够享受到高质量的医疗服务。

这一承诺与蒙大拿州和其他40多个州的想法不谋而合。蒙大拿州和其他40多个州临时放宽了远程医疗服务限制条例,并允许州外医疗机构在新冠疫情期间提供远程医疗服务。

新冠疫情爆发一年来,远程医疗已经得到广泛认可。对于推动了远程医疗发展的措施,一些州正在力求将其永久化。但一些意想不到的后果也随之而来,例如欺诈频发、弱势群体可能面临无法获得服务的问题以及州外和州内医疗机构之间的冲突。

在蒙大拿州,并非人人都欢迎总部位于明尼苏达州的哈泽尔登·贝蒂·福特基金会来此提供远程医疗服务。Rimrock总部位于比林斯,是蒙大拿州规模最大的行为健康医疗机构。其负责人担心,州外医疗机构的涌入可能会使Rimrock失去大量有商业保险的病人。

Rimrock的首席执行官莱内特·科索维奇称,Rimrock有商业保险的病人会给享受Medicaid(医疗补助)的病人带来福利。她说,两者的保险赔付率相差很大,失去有商业保险的病人将对Rimrock的持续运营造成不利影响。

科索维奇说:“只要是公平竞争,我完全支持。”她补充道,她希望可以出台相关规则,确保由于新冠疫情期间限制放宽得以进入蒙大拿州的州外医疗机构遵守与州内医疗机构相同的许可要求。

她说:“他们不接受Medicaid付费,所以他们不会面临我们所面临的严峻考验。我们呼吁出台更多相关立法,让竞争更加公平。”

哈泽尔登·贝蒂·福特基金会的业务拓展副总裁鲍勃·波兹纳诺维奇称,该基金会并不是要挖走任何医疗机构的病人。他说,相反,我们的服务对象是那些无法在15个戒毒和戒酒康复中心的任何一个中心接受治疗的病人。

波兹纳诺维奇指出:“我们认为,像我们这样的民族品牌能够在全国范围内提供医疗服务,对于全国各地的病人具有重要的意义。我认为,这对那些无法获得优质医疗服务的人也很重要,因为他们身处医疗荒原,在那里根本无法获得优质医疗服务。”

美国联邦政府的一项调查估计,全美有5,800个地区、居民区或设施(如监狱)都面临着精神卫生服务提供者短缺的问题,需要6,450名从业者来填补这一缺口。基础医疗需求更大,近7,300个地区缺少专业医护人员。

对于全国范围内的病人来说,远程医疗更易让他们获得医疗服务。位于波士顿的美国东北大学(Northeastern University)24岁的学生阿亚娜·米勒就是其中一名受益者。

她说:“有时候,你根本不需要去诊室。你只需和你的医生简短交谈。我也接受过远程治疗。你不一定要和你的医生待在同一个房间。”

在新冠疫情压力之下,精神卫生和成瘾戒断康复工作更加紧张,越来越需要帮助。哈泽尔登·贝蒂·福特基金会已经加快实施其在新冠疫情爆发前制定的扩张计划,并预计两年内在全美50个州提供远程医疗服务。下一站:亚利桑那州和新墨西哥州。

波兹纳诺维奇说:“我们也听到了一些抱怨,比如‘你们为什么要来我们州?’但他补充道:“更多人欢迎我们进入这个市场,因为他们认为我们会创造一个更大的市场。”

在新冠疫情爆发前,很少有人会通过电脑或电话远程就诊:据KFF提供的数据,2018年,只有2.4%的大型雇主健康计划参与者使用远程医疗服务。这在一定程度上是由于各州的不同政策和联邦法规限制了远程医疗服务的提供地和服务的对象。

但现在,各州正在免除病人共同付费和共同保险要求,以与面对面服务相同的费率赔付远程医疗服务费用,免除许可证要求,允许纯音频就诊,并采取其他一系列措施。

据Epic健康研究网络(Epic Health Research Network)统计的数据,在新冠疫情爆发的最初几个月,随着全国陆续出台封锁措施,远程医疗就诊人数激增,约占总预约人数的十分之七。但到夏天,这一比例下降到五分之一。

现有服务和初创服务正在蓬勃发展。波兹纳诺维奇在对远程医疗就诊人数激增与本世纪初网络繁荣进行比较后指出,基金会的内部研究表明,数百家远程医疗公司已经获得了融资。

他说:“各公司现在有一种抢占地盘的心态。我们发现,由于潜在客户数量巨大,一些市场估值非常疯狂。”

已经投资三家远程医疗公司的佛罗里达州放射科医生阿什利·马鲁说,远程医疗业务突飞猛进,将会促使医疗行业发生永久性改变。更具创新性的虚拟医疗机构将会进入这一领域,可能会对实体医疗机构的医生不利。但他指出,这解决了全国医生短缺的问题。

马鲁说:“全国医学领域将会发生变化。远程医疗将不仅仅局限于某一州,而是真正地根除并颠覆一切。”

州际虚拟医疗不再受约束,这样的前景令一些卫生领域官员担忧。蒙大拿州蓝十字与蓝盾协会(Blue Cross and Blue Shield of Montana)的发言人约翰·多兰称,他和科索维奇一样担心,当地医疗机构可能会遭受重创或倒闭,尤其是在较小的州。

多兰说:“未来医学界必须要使蒙大拿州的病人与蒙大拿州的医疗机构形成一对一服务。”

波兹纳诺维奇说道,哈泽尔登·贝蒂·福特基金会除了向从未接受过服务的人提供服务外,还与一些市场的当地医疗机构建立了合作关系,并向其扩张地的当地医疗机构提供教育和资源。

一些州正在率先制定计划,彻底推进远程医疗改革。蒙大拿州的一项法案于2月9日在众议院获得一致通过,目前尚待参议院通过。

管理蒙大拿州证券和保险专员的政府事务主任杰基·琼斯最近向州议员表明支持该法案,他说:“我们被迫以我们认为我们尚未准备好的方式使用该技术,但事实证明,我们已经准备好了。”

某些病人可能被排除在远程医疗革命之外。《新英格兰医学期刊》(New England Journal of Medicine)发表的一篇文章称,快速、大规模实施远程医疗可能会将老年人、穷人和非英语使用者等一些使用互联网受限或技术知识掌握有限的人们撇在一边。

美国卫生与人类服务部调查办公室的督察长办公室行动事务员迈克·科恩说,与此同时,远程医疗欺诈案件也在“激增”。他说,总的来说,远程医疗是件好事,但随着医学的发展,“肯定会出现滥竽充数之人。”

他说,许多欺诈者想要窃取病人的身份信息,然后在黑市上出售。一些医疗机构的约诊费过高,或者存在乱收费现象,或者未在美国注册或获得许可证。一些骗子为了骗取人们的钱财,谎称可以帮助他人取得新冠疫苗优先接种资格。

科恩说:“我们感觉,远程医疗的应用范围比我们预想的更广泛。如果我们要永久推行远程医疗,我们就要有保障计划完整性和病人安全的有效措施。”

远程医疗即使能够保证最佳运作,也会有不足之处。美国东北大学的学生米勒说,她在今年1月确诊患有新冠肺炎,并有轻微症状。到2月初,她感觉好多了,想让医生面对面对其检查,看看病毒是否对她造成其他影响。

但医生只在网上接诊,而米勒只是通过视频电话回答了医生的问题,她有些失望。

米勒说:“关于新冠病毒,最可怕的是你不知道它会给你带来什么样的影响。我可以说出我的感受,但我不知道是不是会遗漏一些内容,因为我没有接受过专业培训。”(财富中文网)

凯撒健康新闻(Kaiser Health News,KHN)是一家全国性新闻编辑室,专注于深入报道健康问题。政策分析、民意调查及KHN是凯撒家庭基金会(Kaiser Family Foundation ,KFF)的三大运营项目。KFF是一个受捐的非营利组织,向全国人民提供与健康问题有关的信息。

翻译:郝秀

审校:汪皓

哈泽尔登·贝蒂·福特基金会(Hazelden Betty Ford Foundation)于今年2月初开始在蒙大拿州提供远程医疗服务,这家美国最大的非营利成瘾戒断机构承诺,偏远地区的居民在家也能够享受到高质量的医疗服务。

这一承诺与蒙大拿州和其他40多个州的想法不谋而合。蒙大拿州和其他40多个州临时放宽了远程医疗服务限制条例,并允许州外医疗机构在新冠疫情期间提供远程医疗服务。

新冠疫情爆发一年来,远程医疗已经得到广泛认可。对于推动了远程医疗发展的措施,一些州正在力求将其永久化。但一些意想不到的后果也随之而来,例如欺诈频发、弱势群体可能面临无法获得服务的问题以及州外和州内医疗机构之间的冲突。

在蒙大拿州,并非人人都欢迎总部位于明尼苏达州的哈泽尔登·贝蒂·福特基金会来此提供远程医疗服务。Rimrock总部位于比林斯,是蒙大拿州规模最大的行为健康医疗机构。其负责人担心,州外医疗机构的涌入可能会使Rimrock失去大量有商业保险的病人。

Rimrock的首席执行官莱内特·科索维奇称,Rimrock有商业保险的病人会给享受Medicaid(医疗补助)的病人带来福利。她说,两者的保险赔付率相差很大,失去有商业保险的病人将对Rimrock的持续运营造成不利影响。

科索维奇说:“只要是公平竞争,我完全支持。”她补充道,她希望可以出台相关规则,确保由于新冠疫情期间限制放宽得以进入蒙大拿州的州外医疗机构遵守与州内医疗机构相同的许可要求。

她说:“他们不接受Medicaid付费,所以他们不会面临我们所面临的严峻考验。我们呼吁出台更多相关立法,让竞争更加公平。”

哈泽尔登·贝蒂·福特基金会的业务拓展副总裁鲍勃·波兹纳诺维奇称,该基金会并不是要挖走任何医疗机构的病人。他说,相反,我们的服务对象是那些无法在15个戒毒和戒酒康复中心的任何一个中心接受治疗的病人。

波兹纳诺维奇指出:“我们认为,像我们这样的民族品牌能够在全国范围内提供医疗服务,对于全国各地的病人具有重要的意义。我认为,这对那些无法获得优质医疗服务的人也很重要,因为他们身处医疗荒原,在那里根本无法获得优质医疗服务。”

美国联邦政府的一项调查估计,全美有5,800个地区、居民区或设施(如监狱)都面临着精神卫生服务提供者短缺的问题,需要6,450名从业者来填补这一缺口。基础医疗需求更大,近7,300个地区缺少专业医护人员。

对于全国范围内的病人来说,远程医疗更易让他们获得医疗服务。位于波士顿的美国东北大学(Northeastern University)24岁的学生阿亚娜·米勒就是其中一名受益者。

她说:“有时候,你根本不需要去诊室。你只需和你的医生简短交谈。我也接受过远程治疗。你不一定要和你的医生待在同一个房间。”

在新冠疫情压力之下,精神卫生和成瘾戒断康复工作更加紧张,越来越需要帮助。哈泽尔登·贝蒂·福特基金会已经加快实施其在新冠疫情爆发前制定的扩张计划,并预计两年内在全美50个州提供远程医疗服务。下一站:亚利桑那州和新墨西哥州。

波兹纳诺维奇说:“我们也听到了一些抱怨,比如‘你们为什么要来我们州?’但他补充道:“更多人欢迎我们进入这个市场,因为他们认为我们会创造一个更大的市场。”

在新冠疫情爆发前,很少有人会通过电脑或电话远程就诊:据KFF提供的数据,2018年,只有2.4%的大型雇主健康计划参与者使用远程医疗服务。这在一定程度上是由于各州的不同政策和联邦法规限制了远程医疗服务的提供地和服务的对象。

但现在,各州正在免除病人共同付费和共同保险要求,以与面对面服务相同的费率赔付远程医疗服务费用,免除许可证要求,允许纯音频就诊,并采取其他一系列措施。

据Epic健康研究网络(Epic Health Research Network)统计的数据,在新冠疫情爆发的最初几个月,随着全国陆续出台封锁措施,远程医疗就诊人数激增,约占总预约人数的十分之七。但到夏天,这一比例下降到五分之一。

现有服务和初创服务正在蓬勃发展。波兹纳诺维奇在对远程医疗就诊人数激增与本世纪初网络繁荣进行比较后指出,基金会的内部研究表明,数百家远程医疗公司已经获得了融资。

他说:“各公司现在有一种抢占地盘的心态。我们发现,由于潜在客户数量巨大,一些市场估值非常疯狂。”

已经投资三家远程医疗公司的佛罗里达州放射科医生阿什利·马鲁说,远程医疗业务突飞猛进,将会促使医疗行业发生永久性改变。更具创新性的虚拟医疗机构将会进入这一领域,可能会对实体医疗机构的医生不利。但他指出,这解决了全国医生短缺的问题。

马鲁说:“全国医学领域将会发生变化。远程医疗将不仅仅局限于某一州,而是真正地根除并颠覆一切。”

州际虚拟医疗不再受约束,这样的前景令一些卫生领域官员担忧。蒙大拿州蓝十字与蓝盾协会(Blue Cross and Blue Shield of Montana)的发言人约翰·多兰称,他和科索维奇一样担心,当地医疗机构可能会遭受重创或倒闭,尤其是在较小的州。

多兰说:“未来医学界必须要使蒙大拿州的病人与蒙大拿州的医疗机构形成一对一服务。”

波兹纳诺维奇说道,哈泽尔登·贝蒂·福特基金会除了向从未接受过服务的人提供服务外,还与一些市场的当地医疗机构建立了合作关系,并向其扩张地的当地医疗机构提供教育和资源。

一些州正在率先制定计划,彻底推进远程医疗改革。蒙大拿州的一项法案于2月9日在众议院获得一致通过,目前尚待参议院通过。

管理蒙大拿州证券和保险专员的政府事务主任杰基·琼斯最近向州议员表明支持该法案,他说:“我们被迫以我们认为我们尚未准备好的方式使用该技术,但事实证明,我们已经准备好了。”

某些病人可能被排除在远程医疗革命之外。《新英格兰医学期刊》(New England Journal of Medicine)发表的一篇文章称,快速、大规模实施远程医疗可能会将老年人、穷人和非英语使用者等一些使用互联网受限或技术知识掌握有限的人们撇在一边。

美国卫生与人类服务部调查办公室的督察长办公室行动事务员迈克·科恩说,与此同时,远程医疗欺诈案件也在“激增”。他说,总的来说,远程医疗是件好事,但随着医学的发展,“肯定会出现滥竽充数之人。”

他说,许多欺诈者想要窃取病人的身份信息,然后在黑市上出售。一些医疗机构的约诊费过高,或者存在乱收费现象,或者未在美国注册或获得许可证。一些骗子为了骗取人们的钱财,谎称可以帮助他人取得新冠疫苗优先接种资格。

科恩说:“我们感觉,远程医疗的应用范围比我们预想的更广泛。如果我们要永久推行远程医疗,我们就要有保障计划完整性和病人安全的有效措施。”

远程医疗即使能够保证最佳运作,也会有不足之处。美国东北大学的学生米勒说,她在今年1月确诊患有新冠肺炎,并有轻微症状。到2月初,她感觉好多了,想让医生面对面对其检查,看看病毒是否对她造成其他影响。

但医生只在网上接诊,而米勒只是通过视频电话回答了医生的问题,她有些失望。

米勒说:“关于新冠病毒,最可怕的是你不知道它会给你带来什么样的影响。我可以说出我的感受,但我不知道是不是会遗漏一些内容,因为我没有接受过专业培训。”(财富中文网)

凯撒健康新闻(Kaiser Health News,KHN)是一家全国性新闻编辑室,专注于深入报道健康问题。政策分析、民意调查及KHN是凯撒家庭基金会(Kaiser Family Foundation ,KFF)的三大运营项目。KFF是一个受捐的非营利组织,向全国人民提供与健康问题有关的信息。

翻译:郝秀

审校:汪皓

When the Hazelden Betty Ford Foundation began offering telehealth services in Montana in early February, the nation’s largest nonprofit addiction treatment provider promised quality care for far-flung residents without their even having to leave home.

That promise was what Montana and more than 40 other states had in mind when they temporarily relaxed rules restricting telehealth services and allowed out-of-state providers to hold remote patient visits for the duration of the COVID-19 pandemic.

A year into the pandemic, telehealth has become widely accepted. Some states are now looking to make permanent the measures that have fueled its growth. But with it have come some unintended consequences, such as a rise in fraud, potential access problems for vulnerable groups, and conflicts between out-of-state and in-state health providers.

In Montana, for example, not everybody cheered the virtual arrival of the Minnesota-based Hazelden Betty Ford Foundation. The head of Montana’s largest behavioral health provider, Billings-based Rimrock, worried that an influx of out-of-state providers could lead to Rimrock’s losing a significant number of its privately insured patients.

Rimrock patients with private insurance subsidize patients who are on Medicaid, CEO Lenette Kosovich said. The difference in insurance reimbursement rates between the two is so great that the loss of those privately insured patients would hamper Rimrock’s operations, she said.

“I’m all for competition, as long as it’s fair competition,” Kosovich said. She added that she would like to see rules in place ensuring that out-of-state providers that enter Montana via the relaxed regulations of the pandemic meet the same licensing requirements as in-state providers.

“They don’t take Medicaid, so they don’t have to go through the same rigors,” she said. “We’ve been really very vocal that we want more legislation that speaks to that. Even the playing field.”

Hazelden Betty Ford is not out to poach anybody else’s patients, said Bob Poznanovich, the foundation’s vice president of business development. Instead, it’s targeting patients who aren’t receiving care and can’t go to one of its 15 drug and alcohol rehabilitation centers, he said.

“We think it’s important that a national brand like ours is able to provide care nationally,” Poznanovich said. “That becomes important to our patients, who come from all over the country. It’s also important, I think, for people who can’t access quality care, who are in some health care deserts where there just isn’t good care.”

A federal government survey estimated that a shortage of mental health providers exist in 5,800 geographic areas, populations or facilities—such as prisons—across the U.S., with 6,450 practitioners needed to fill the gaps. For primary care, the need is even greater, with nearly 7,300 areas short of health professionals.

For patients nationwide, telehealth can make getting medical care much easier. Ayanna Miller, a 24-year-old student at Northeastern University in Boston, is among those embracing the technology.

“Sometimes you don’t really need to go into the office. You really just need, like, a quick conversation with your doctor,” she said. “I’ve also done telehealth for therapy. You don’t necessarily need to be in the same room with your therapist.”

As the stresses of the pandemic have strained mental health and addiction recovery, the need for help has increased. Hazelden Betty Ford has accelerated its pre-COVID plans for expansion and expects to offer telehealth services in all 50 states within two years. Next on deck: Arizona and New Mexico.

“We’ve heard grumblings, like ‘Why are you coming into our state?’” Poznanovich said. But, he added, “More people have welcomed the entry into the marketplace because they think that we will help create a bigger marketplace.”

Before COVID, remote doctor visits by computer or phone were rare: Just 2.4% of enrollees in large-employer health plans used a telehealth service in 2018, according to KFF. That was due in part to different policies among states and federal rules that limited where and to whom telehealth services could be offered.

But now, states are waiving patient copays and coinsurance, reimbursing telehealth services at the same rate as in-person services, waiving licensure requirements, and allowing audio-only visits, among other measures.

In the first months of the pandemic, with lockdowns the norm throughout the country, telehealth visits surged to about seven in 10 medical appointments, according to the Epic Health Research Network. That had tapered off to about one in 5 visits as of summer.

Existing and startup services are flourishing. Poznanovich compared the surge to the dot-com boom of the early part of the century, noting that the foundation’s internal studies show that hundreds of telehealth companies have received financing.

“There is a land-grab mentality right now,” he said. “We’re seeing some really crazy market valuations because of the potential number of clients.”

Today’s rush will lead to permanent changes in health care, said Florida radiologist Dr. Ashley Maru, who invested in three telehealth companies. More innovative virtual providers entering the field may come at the expense of physicians who see patients in brick-and-mortar offices. But it also presents a solution to the national shortage of doctors, he said.

“You’re going to see a national change in the landscape of medicine,” Maru said. “They’re going to be able to cross state lines and really uproot and disrupt everything.”

The prospect of unfettered interstate virtual health care worries some health industry officials. Blue Cross and Blue Shield of Montana spokesperson John Doran said he shares Kosovich’s concerns that local providers could suffer or be driven out of business, particularly in smaller states.

“The future of medicine has to include connecting a Montana patient to a Montana provider,” Doran said.

Poznanovich said that, besides providing services to people who weren’t receiving them before, Hazelden Betty Ford Foundation forms partnerships with local providers in some markets and offers education and resources to providers where it expands.

Some states are forging ahead with plans to make their telehealth changes permanent. A Montana bill passed the state House of Representatives unanimously Feb. 9 and is pending in the Senate.

“We were forced to use technologies in ways that we maybe thought we weren’t ready for and it turns out that we were,” Jackie Jones, government affairs director for the state’s securities and insurance commissioner, recently told state lawmakers in supporting the bill.

Certain patients may be left out of the telehealth revolution. The rapid, wide-scale implementation of telemedicine could leave behind people with limited internet access or tech literacy, including the elderly, poor and non-English speakers, according to a New England Journal of Medicine article.

Meanwhile, telehealth fraud cases have “gone through the roof,” said Mike Cohen, an operations officer with the Office of Investigations of the Department of Health and Human Services’ inspector general’s office. Telehealth in general is a good thing, he said, but with any popular medical advancement, “there’s going to be rats on the ship.”

Many fraudsters are trying to steal patients’ identities and sell them on the black market, he said. Some providers are overcharging for appointments, are billing for services that weren’t given, or are not registered or licensed in the U.S. Some scammers offer to put a patient at the front of the line for a COVID vaccine in exchange for payment.

“Our sense is that it’s more widespread than we envisioned,” Cohen said. “If we’re going to make this permanent, we need to make sure there’s guardrails to ensure programmatic integrity and also patient safety.”

Even when working optimally, telehealth can have its limits. Miller, the Northeastern University student, said she was diagnosed with COVID in January and had mild symptoms. By early February, she felt better and wanted to schedule an in-person physical with her doctor to find out if the virus had affected her in other ways.

The doctor was taking only virtual appointments, and Miller was left feeling unsatisfied just answering the doctor’s questions by video call.

“The scariest thing about COVID is you just don’t know how it’s going to impact you,” Miller said. “I can say how I feel, but I don’t know if there’s anything that I’m not catching because I’m not trained.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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