She lives close enough to walk to the federally qualified health center but didn’t feel comfortable leaving her home in those early days, let alone venturing into a medical office. But she’s been able to access care through phone and video chats.

“For me, it’s been such a lifesaver, such a blessing,” said King, 69. “Otherwise, I would not have been able to talk to my behavioral health therapist for this whole entire time. The fact that I could speak with her on the phone every week—and then we figured out a way that we could actually see each other on video—it’s just a blessing.”

Melanie Stengel Photo.

Darcy Cusano, an advanced practice registered nurse at the Community Health & Wellness Center in Torrington, meets with a telehealth patient.

Telehealth has helped connect patients to providers over the past year. It has been particularly crucial in keeping federally qualified health center (FQHC) patients, many of whom are people of color and on Medicaid, connected to medical care during the pandemic.

But while telehealth has brought some health care benefits and kept those already receiving services connected to their providers, national reports by Robert Wood Johnson Foundation and Health Affairs show that the technology has done little to reach new patients, and those with limited English proficiency had low rates of telehealth use.

FQHCs are community-based health care providers that receive federal funds to provide primary care services in underserved areas. They must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients.

According to Ken Lalime, CEO of the Community Health Center Association of Connecticut, 62% of FQHC patients in Connecticut are on Medicaid, 10% are on Medicare and 15% are uninsured. Most, around 90%, have income that’s twice the federal poverty level, and more than half don’t speak English as their first language. There are 17 FQHCs in Connecticut.

FQHCs saw their number of patient visits plummet as soon as the COVID-19 pandemic hit, Lalime said. Providers wondered how they would reach their at-risk patients and get them the care they needed. Telehealth quickly emerged as the answer.

“Just because we built it doesn’t mean that folks will come. What most data are showing across the country is that [telehealth] made access more readily available for people who already had access.”

 

Tekisha Dwan Everette,

executive director of Health Equity Solutions

On March 10, 2020, Gov. Ned Lamont issued an executive order that, among other things, allowed Medicaid to cover telehealth visits. On May 10, 2021, he signed legislation into law that extends that provision for another two years.

“Telehealth meant everything for people getting access to care in the pandemic,” said Jill Zorn, senior policy officer at the Universal Health Care Foundation of Connecticut. “From a health care perspective, not being able to see your doctor was a real problem. Having [insurers, including Medicaid] pay for telehealth was huge. If there’s any good thing that came out of the pandemic, this is one of them.”

When COVID shutdowns began, FQHCs in the state saw patient visits drop by up to 80%. Once the state allowed telehealth, some centers conducted as much as 80% of their visits that way, and over the past year or so, about 50% of all FQHC visits have been telehealth visits, Lalime said. The number of telehealth visits is starting to drop now, he said, as patients feel more comfortable scheduling in-person visits.

‘A Game Changer,’ But Not For All

Via telehealth, King has continued her care plan, gotten referrals for any tests or scans she needs, and ensured her prescriptions stayed up to date.

“All of the things that I needed to have done because I have access to my providers through telemedicine, I’ve been able to have those things done,” she said.

Staff at Southwest Community Health Center in Bridgeport had long been interested in telehealth, but it was never feasible before because Medicaid wouldn’t cover the expense, said the center’s president and CEO, Mollie Melbourne.

“Telehealth was a game-changer for us. It really helped us retain that connection with our patients,” Melbourne said. She added that it was essential for patients receiving mental or behavioral health services and those with chronic illnesses.

“Technology was a challenge [early on] but the concept of telemedicine, they fell right into. The patients seem to love it, especially for behavioral health,” Melbourne said. “And once we got over the technological hurdles, the providers really enjoy it.”

Telehealth eliminates various barriers to care, including the need for transportation, said Joanne Borduas, CEO of Community Health & Wellness Center, which has locations in Torrington and Winsted.

“We have no public transportation at all” in the area, she said. “It’s a challenge as it is, without a pandemic, trying to keep our patients coming back and staying connected with them. The ability to stay connected to them is so critical to their health and wellness,” she said.

Without telehealth, Borduas said, “we probably would have seen an enormous increase in adverse outcomes. What that would have caused is just this cycle throughout the pandemic of [patients] having their needs met in the emergency room. We were very happy that we were able to use telehealth.”

Telephone telehealth, in particular, has been a lifeline for many, she said.

“Not all of our patients have the ability or the money to buy computers, so the ability to do video telemedicine was challenging,” she said. “The telephone-only component was really a lifeline for many of our patients; it became such a huge component.”

Ken Lalime

Telehealth has brought various benefits but also new challenges.

“There were definitely some growing pains,” Lalime said. “To get it rolling, it took patient education and system education. Connecticut responded fairly quickly to this, but it was not instantaneous. It took some time.”

The Community Health Center Association is studying the impact of telehealth and how well it worked during the pandemic, he said.

‘The Key To Equity?’ Not So Fast

While telehealth likely helped centers recoup the patients they had lost in the pandemic’s early days, early data show it hasn’t improved overall access to care, said Tekisha Dwan Everette, executive director of the advocacy group Health Equity Solutions.

“Just because we built it doesn’t mean that folks will come,” she said, noting many FQHC patients lack access to the broadband internet needed for video visits. “What most data are showing across the country is that [telehealth] made access more readily available for people who already had access.”

She’s encouraged by proposals to expand broadband access in the state, she said, but other questions remain. As centers consider telehealth’s role, they need to examine whether they are using it to be truly equitable. They need to assess whether it’s accessible to patients across various races and age demographics, for instance, and whether primary care is fully embracing it, she said.

“Everybody thinks this is the key to equity—which it can be—but when they start to look at their data, they realize it isn’t,” she said. “I think we can do it right; I don’t necessarily think we did it right.”

“From a health care perspective, not being able to see your doctor was a real problem. Having [insurers, including Medicaid] pay for telehealth was huge. If there’s any good thing that came out of the pandemic, this is one of them.”

 

Jill Zorn, senior policy officer at the Universal Health Care Foundation of Connecticut.

FQHCs will be able to use telehealth for at least the next two years, but leaders hope it is here to stay.

“There are some things, we all know, that simply can’t be done over telemedicine,” Melbourne said. “But I see it as a critical tool. I hope it does not go away.”

Borduas said, “There will always be a place for telemedicine. We’re going to prepare to do this forever. That technology will be embedded in everything we do going forward.”

Telehealth will never fully replace in-person care, Lalime said, but “it’s part of the toolkit. Over the next couple of years, I think it’s going to evolve. It’s a very exciting time.”

They are among thousands of physicians and other health care professionals across the country who have made coronavirus-prompted career changes such as closing practices, joining larger health systems and retiring early.  The reasons for the moves vary from declines in income due to fewer inpatient visits to increased operational costs for personal protective equipment (PPE) and fears of contracting the coronavirus known as SARS-CoV-2.

Health care advocates say the changes will exacerbate physician shortages, further erode the existence of private practices, decrease patient choice of doctors and obstruct continuity of patient care. A January report in Health Affairs, a peer-reviewed journal of health policy research, said: “Consolidation tends to lead to higher prices without strong evidence of quality improvements.”

Photo Courtesy of Dr. Windels.

Dr. Cecile Windels sold her medical practice in October to Stamford Health.

“The national trends are definitely happening in Connecticut,” said Dr. Gregory Shangold, president of the Connecticut State Medical Society. It will be more challenging for state residents to access high-quality care when physician shortages already exist, particularly in underserved, low-income areas, he said.

A national Physicians Foundation survey last July found that COVID-19 prompted the closing of more than 16,000 practices, 76% in private practice.  The closings represented 8% of respondents. Another 8,000 closings were planned within a year. In addition, 72% of respondent doctors said their income dropped, 43% cut staff, and 16% had changed jobs or planned to within a year.

Ellen Andrews, executive director of the nonprofit Connecticut Health Policy Project, said fewer providers treating more people mean less time in a doctor’s office, higher prices and potential poor fits between patients and doctors because of such issues as language differences and transportation.

Andrews said that since mental health needs are skyrocketing during COVID-19, she is concerned about access to appropriate care. “With your surgeon, you don’t care if he’s a nice guy or not,” she said. “With mental health providers, you really do need a connection.”

Shangold heads a Willimantic-based emergency medicine practice that contracts with hospitals. He said he already sees people in emergency rooms for care typically provided by primary care doctors and specialists. “They can’t get one,” he said.

Based on phone calls from physicians to the Fairfield County and Hartford County medical associations, there has been “a very definite uptick in the number of retirements and the number of physicians who have sold practices and work for someone else,” said Mark Thompson, their executive director. He said doctors have been seeking advice about how to close a practice and how to establish the monetary value of a practice. He would not provide statistics.

In dentistry, the American Dental Association reported 72.7% of Connecticut dentists WITH lower patient volumes since the start of the pandemic, according to a survey conducted the week of Jan. 18. This was the fifth-highest in the country. Nationally, 56.2% of dentists reported lower patient visits.

Connecticut dentists considering selling or merging their practices will likely wait until after the pandemic because lower patient volume and reduced income hurt practices’ values, said Dr. Tam Le, president of the Connecticut State Dental Association.

For Wilk, who is 65, the pandemic struck from multiple fronts. His daughters said that they wouldn’t let him see his grandchildren if he kept seeing patients. Many patients didn’t want to go into the office. His surgical assistant couldn’t work because her child’s school closed. His other employee worried about contracting coronavirus.

Photo Courtesy of Dr. Wilk.

Dr. Arthur Wilk, an oral surgeon, closed his Clinton practice.

“Basically, we had a family meeting. It was mutually decided that it was not worth it,” Wilk said.

After closing in March, when elective surgeries were prohibited, Wilk reopened in June for patients who had been having ongoing treatment “to make sure they were squared away,” he said. He sent a letter to patients announcing his decision and made referrals to other surgeons.

Windels, the Darien pediatrician, said that when COVID-19 hit, her patient load dropped by 60%. She said finding available PPE was difficult, prices were astronomical, and other supplies, like strep and flu tests, were hard to get. She said she spent a lot of time on the phone answering parents’ questions about their children’s health, which she couldn’t charge for. She took a lower salary to avoid laying off staff.

A federal Paycheck Protection Program loan kept her afloat and prevented staff layoffs. “I would have had to close my door,” she said. She signed an agreement with Stamford Health Medical Group in October.

Windels still practices pediatrics in the office she has had since 2006. But now she is an employee of the health system, which handles the business side. “I don’t have to stay up at night worrying about my bills,” she said.

Dr. Rodrigo Acosta, president and chief executive officer of Stamford Health Medical Group, said he is in talks with two other medical practices to join the system. He also said that he has hired doctors who were laid off or had their salaries cut during the pandemic.

From 2016 to 2018, the number of Connecticut physicians affiliated with health systems grew in every part of the state, according to an analysis of “metropolitan statistical areas” by Health Affairs. For example, in the Bridgeport area, which includes Stamford and Norwalk, the number of doctors associated with the Yale New Haven Health System went from 33% to 42%. In the New Haven-Milford area, doctors associated with Yale New Haven rose from 29% to 43%.  The national growth was the fastest in the Northeast and the Midwest.

Graphic by Bonnie Phillips

Source: Health Affairs

Health systems benefit doctors by handling operating costs, negotiating with insurance companies for reimbursement, maintaining data for increased federal regulatory demands, and providing a regular paycheck.

Andrews said she has asked the General Assembly to establish a task force of independent experts to analyze the implications. “People do not understand how consolidation is impacting cost and consumer choice,” she said.

Wilk now works part-time at Yale New Haven Hospital, mainly supervising residents performing oral surgeries. He said the hospital could enact COVID-19 safety procedures that a small practice like his could not afford, such as more support staff, regular COVID-19 testing for patients, sufficient PPE, and a dedicated staff to clean and disinfect treatment areas after each patient.

Wilk said closing his practice ended relationships with long-time patients.

“That’s not the way you’d like to part with them,” he said.

The more legal services they had, the better they fared, experiencing reduced symptoms of Post-Traumatic Stress Disorder (PTSD) and psychosis, spending less money on abused substances and having better housing situations, the study found. In addition, the study concluded that mental health was improved even if veterans lost their legal battles.

The study analyzed the legal/medical partnerships between the nonprofit Connecticut Veterans Legal Center (CVLC) and VA Connecticut Healthcare and between New York Legal Assistance and two VA hospitals. It looked at free legal help given to 950 veterans from 2014 through 2016 and its effects on the mental health, housing, and income of 148 of those veterans followed closely for a year. Income improved from VA benefits, but not from employment, the study reports.

“We are really thrilled,” said Margaret Middleton, executive director of the CVLC. She said the study confirms “an anecdotal sense that we are providing real relief for our clients.”

Desirea Still Photo.

Jack Tsai, an associate professor of psychiatry and researcher with Margaret Middleton, head of CVLC.

The veterans’ most prevalent legal needs related to: VA benefits; housing, such as evictions; family issues, such as child support and divorce; and consumer problems, including credit card debt.

Sidley Cousins, 38, a Navy veteran with bipolar disorder, said his mental health improved after getting free legal help and that he is planning to be married. Cousins, who works in security in East Hartford, said the Connecticut Veterans Legal Center helped him obtain a divorce, VA disability benefits and a settlement after his car was stolen. “They helped me tremendously,” said Cousins, of New Britain, who served from 2000 through 2004.

Nationally, there are 15 medical/legal partnerships between the VA and legal services organizations, according to the study by lead author Jack Tsai, an associate professor of psychiatry at the Yale School of Medicine and a core investigator for Veterans Affairs, New England. The study was published in Health Affairs on Monday. There are 168 VA medical centers and 1,053 VA outpatient clinics nationwide.

The study shows a need for more partnerships and for proposed federal legislation that would provide funding toward legal services given at VA facilities, said Middleton, whose legal center is based at the VA Errera Center in West Haven. Her organization helps veterans who have faced homelessness and mental illness with legal problems related to health care, housing, and income.

U.S. Sen. Richard Blumenthal, D-Conn., a co-sponsor of a bill to provide funding for VA legal services, said that “access to expert legal services within the VA could mean the difference between a safe, stable home and homelessness.”  He called the fact that 1 in 10 veterans is homeless, “a searing, staggering national failure.”

The VA has issued guidance to its medical centers on working with community legal providers, but it has put “little focus on civil legal problems that can affect health and impede recovery,” the study states, adding that in surveys, veterans consistently report legal help among their top unmet needs.

The study suggests a potential savings in medical care and housing services for veterans when they access legal services, but didn’t do an analysis on it. However, it states that the two legal organizations estimated the average cost of each resolved legal issue ranged from $207 to $405. The study calls this “a small amount relative to the average annual direct costs of $10,000 to $60,000 to provide care to a person who is chronically homeless, has a severe mental illness, or both.”

Middleton said, “This could mean a relatively low-cost intervention that improves people’s lives.”

Meanwhile, she said the finding that mental health improved even when a case is lost was “unanticipated.” She said it means that “the very fact that you have a lawyer talk to you about your legal issue or have someone work with you on it, may have value.”

Of the 705 Connecticut veterans included in the study, most were single or divorced, white males earning less than $21,000 annually. Twenty percent served in Iraq or Afghanistan.

Middleton said the study, funded by the Bristol-Myers Squibb Foundation, is “really a starting point for trying to understand how integrating legal services into medical care works, what the mechanism is for how people’s health may improve, and how we can best provide those services to make them the most effective.”

Individuals who are already in ongoing studies must be dropped if they are incarcerated – compromising the ability of researchers to examine racial disparities in health outcomes studies, the Yale team says in the May issue of the journal Health Affairs.

“A black man who begins a research study is less likely to follow up because he is statistically more likely to be jailed or imprisoned during the study than his white counterpart,” said the study’s first author, Dr. Emily Wang, assistant professor at Yale School of Medicine. The impact of incarceration on health outcome studies was far less among white men, white women, and black women.

The study found that during the past three decades, high rates of incarceration of black men may have accounted for up to 65 percent of the loss of follow-up among this group. Conditions such as cardiovascular disease and sickle cell disease are more common among black men than white men, and have complex factors that influence illness and death. This makes it important for analysts to have access to a large number of cases, so that they can draw statistically significant conclusions, the researchers said.

In 1978 the federal government restricted research on prison inmates in medical studies — the result of decades of unethical research in correctional institutions. The government regulations bar study subjects from participating once they are incarcerated unless the study investigators apply for special permission through their institutional review board (IRB). If studies do not specify otherwise, community-recruited participants who enroll in studies cannot be followed while they are incarcerated. In certain jurisdictions, they cannot be followed after their release.

Wang and her co-authors examined the protocols of 14 studies funded by the National Heart, Lung, and Blood Institute. They looked for studies that had received IRB protocols to follow prisoners, and also looked at how much loss to follow-up there was. They found that none of the studies received IRB approval for prisoner follow-up; the team then estimated how many individuals may have been incarcerated during the time period, based on national data.

Under current circumstances, Wang said, the results of longitudinal studies may fail to accurately represent the experience of black populations and may bias estimates of racial disparities by either excluding people in prison or discontinuing longitudinal follow-up at the time of incarceration.

“We are missing opportunities to study the outcomes of research on this population, so treatments can be tailored,” Wang said. “It is important that research subjects who are incarcerated be allowed to continue participating in observational research that poses minimal risk to the participants.”

“Better Health: Everyone’s Responsibility,” set for Sept. 17 at the Connecticut Convention Center, Hartford, is a step in bringing patients and providers together to discuss joint decision-making in medical care – from medication management, to end-of-life care, to navigating provisions of the Affordable Care Act. The goal of the summit – open to the public – is to break down barriers between providers and the people they serve, by giving both sides a crash course in key health-care issues and effective ways of communicating.

“The most under-utilized resource in health care is the patient,” said Dave deBronkart, an international patient-engagement advocate known as “e-Patient Dave” who will be the keynote speaker at the conference. “Patients perform better when they are informed better.”

The conference comes in the wake of a study in Health Affairs that showed that patients who actively participate in decision-making with their health-care providers have better health outcomes and lower costs. Of 33,000 patients studied, researchers found that patients who did not actively participate in their health care had 8 percent to 21 percent higher costs than patients with high engagement levels.

The conference, hosted by CT Partners for Health, a group of 40 health-care organizations convened by Qualidigm, the state’s Medicare consulting company, will feature breakout sessions on advance-care planning, patient empowerment through technology, and health-care reform. All of the sessions are geared to engaging patients to “actively assist in managing their own health care through informed choices,” said Tim Elwell, CEO of Qualidigm. “Our hope is that by providing a venue for patients and providers to interact, innovation and mutual understanding will result.”

Among the sessions is one that will focus on “motivational interviewing,” a method for improving communication between providers and patients. Thomas Broffman, assistant professor of social work at Eastern Connecticut State University, will explain and demonstrate a “new paradigm” in communicating that is intended to get patients engaged in improving their own health. In motivational interviewing, doctors ask questions such as, “Where would you like to be in two years, and how can we work together to get you there?” instead of simply giving directions to a patient to lose weight, eat healthier or make other changes.

Another session, led by Stephen P. Kiernan, author of the book “Last Rights,” will discuss informed decision-making in end-of-life care. A 2013 report on hospice utilization by Hospice Analytics identified Connecticut as having one of the lowest rates in the nation in 2011 in terms of mean days of utilizing hospice care. The session is intended to educate consumers about ways to make their end-of-life preferences known, in order to avoid unwanted stays in nursing homes or hospitals, and to discuss alternatives with providers.

Nora Duncan, director of the Connecticut AARP, and Dr. Kenneth Sacks, medical director of the Connecticut State Medical Society-IPA, will team up to outline key provisions of the Affordable Care Act.

Melissa Tait and Dagmara Scalise of Primacy, a digital consulting firm in Farmington that serves a number of health-care institutions, will lead a workshop on how technology is changing today’s patient experience, headlined, “From Your Home to the Waiting Room: Technology’s New Role in Healthcare.”

The conference runs from noon to 6 p.m., with a $10 registration fee to help defer costs. Participants are invited to stay for a reception and dinner, at $25 per ticket, at which healthcare strategy expert Nathan Kaufman will discuss emerging trends in healthcare. The evening ends with a performance by Frank King, known as “the cardiac comedian.”

To register for the conference, go here.