A10 N THE NEW YORK TIMES, MONDAY, AUGUST 3, 2020Tracking an OutbreakPublic Health
Telemedicine is having its mo-
ment. Over the last few months,
millions of people have relied on
video or telephone calls to talk to
their doctors. But as the pandemic
moves across the United States,
and eventually recedes in some
places, how long will the moment
last?
While patients used virtual vis-
its to avoid overcrowded and po-
tentially infectious doctor’s offices
or emergency rooms, many are
returning to face-to-face appoint-
ments in cities where the threat
has subsided.
And insurance payments for
telehealth services, especially at
full cost, may only be temporary.
Medicare’s coverage of a broad
range of services is slated to end
when the coronavirus no longer
poses a public health emergency.
Private insurers, which followed
the federal government’s lead,
could revert to paying doctors for
virtual visits at a fraction of the
cost for traditional visits, if any-
thing at all.
Some of the nation’s biggest in-
surers, like UnitedHealthcare and
Anthem, say they haven’t decided
beyond September or October on
whether to extend the policies
they adopted that allowed for cov-
erage in lieu of doctors’ visits dur-
ing the coronavirus crisis.
“The concern everyone in the
industry has is that reimburse-
ment is in jeopardy,” said Dr. Mia
Levy, the director of the cancer
center at Rush University Medical
Center in Chicago, which treated
patients virtually during the
height of the pandemic. “Because
of telehealth, we were able to stay
actively engaged with our pa-
tients,” she said.
While there is broad bipartisan
support for telehealth coverage,
Congress would have to pass spe-
cific legislation to make some of
Medicare’s changes permanent.
“Reversing course would be a
mistake,” said Seema Verma, the
administrator for the federal pro-
gram, which reimbursed doctors
the same for virtual visits, includ-
ing those over the telephone, as
for in-person ones and relaxed
rules about who can use
telemedicine.
About nine million people under
traditional Medicare used
telemedicine services during the
early months of the crisis. Early
data does not show wide varia-
tions in use by race or ethnicity.
“It was really a no-brainer for
us,” Ms. Verma said.
And spending on telemedicine
services during the first peak of
the coronavirus pandemic in the
United States underscores the de-
mand. In addition to federal
spending through Medicare,
nearly $4 billion was billed nation-
ally for telehealth visits during
March and April, compared to less
than $60 million for the same two
months of 2019, according to FAIR
Health, a nonprofit group that an-
alyzes private health insurance
claims.
But to convince insurers they
should continue paying for virtual
care, doctors must demonstrate
they can move beyond treating
simple respiratory infections to
caring for patients with chronic
conditions like depression or dia-
betes. “From the perspective of
managing the cost and quality,
there’s a lot we don’t know about
telemedicine,” said Dr. Rahul Ra-
jkumar, the chief medical officer at
Blue Cross Blue Shield of North
Carolina.
BlueCross BlueShield of Ten-
nessee says it is the first major in-
surer to make coverage of tele-
health services permanent, but it
has not yet determined how much
it will eventually pay for the care.
A few insurers, including Cigna
and the Blue Cross plan in North
Carolina, said they will continue to
cover telehealth services at pan-
demic levels through the end of
the year.
“We need to give providers time
to get more comfortable,” said Dr.
Scott Josephs, the chief medical
officer for Cigna. To make remote
medicine successful and worth-
while, doctors and medical groups
need to invest in technology and
train staff. “If they don’t have the
time, they won’t make the invest-
ments,” he said.
The biggest hurdle to wide-
spread adoption by both the gov-
ernment and insurers is the po-
tential cost.
Lawmakers are reluctant to
pass any bill that would signifi-
cantly add to Medicare’s budget,
with the government already
spending a total of some $750 bil-
lion a year.
And private insurers see
telemedicine as a way to save
them money, said Sabrina Cor-
lette, a research professor atGeorgetown University, who
helped author a recent report on
how the companies responded to
the pandemic. “Unless they are
required to by the states or federal
government, a lot of carriers will
try to reimburse less for tele-
health than an in-person visit,”
she said.
For those at risk, telemedicine
is particularly valuable. When a
fever sent Susan Varak, 45, who
has breast cancer, to the emer-
gency room during the height of
Chicago’s outbreak in April, she
felt as if she were “walking into
this war zone,” she said, because
she was so terrified of catching
the virus.
She appreciates she still can see
her oncologist remotely. “I don’t
think it’s absolutely necessary to
be face-to-face every couple of
weeks,” she said.
Other patients like the conven-
ience. David Collins, 67, didn’t
have a choice when he had a 20-
minute video visit in March to rule
out a diagnosis of coronavirus.
Like many practices during the
pandemic, the Kelsey-Seybold
Clinic, a large physician group in
Houston, was not allowing most
patients to come in.
“I loved it because it saved me alot of time.” he said, adding “I’d
much rather do that than drive
across town and look for parking.”
But, a few months later, he did-
n’t hesitate to go to the clinic for
his checkup. “There’s a little more
hands-on required,” he explained,
like getting a physical exam and
having his blood pressure taken.
Not everything can be done virtu-
ally, he said. “If you break your
arm, an e-visit isn’t going to help
you at all,” he said.
After seeing about 90 percent of
its patients virtually, Kelsey-Sey-
bold has “almost flip-flopped
back,” said Dr. Donnie Aga, an in-
ternist who oversees telehealth
for the group. Most patients seem
to prefer an in-person appoint-
ment. “You could really see that
people missed coming in,” he said.
With coronavirus cases now at
epidemic levels in Texas, the clinic
wants to shift to dividing visits to
half virtual, half in person.
“You’ve got to have a balance, for
sure,” Dr. Aga said.
But how doctors and insurers
can do that is still unknown.
“We need to see where the equi-
librium ends up,” said Dr. Andrea
Gelzer, the corporate chief medi-
cal officer for AmeriHealth Cari-
tas, a Medicaid managed carecompany. “If the total number of
visits far exceeds pre-Covid, I
don’t think that’s sustainable,” she
said. Additional visits that do not
improve patients’ health will only
result in higher costs.
Doctors have to be more dis-
criminating about which patients
to see remotely, said Rita Nu-
merof, a health care consultant.
Telemedicine “was a solution to
an immediate problem,” she said,
and doctors did not have clear cri-
teria about who should be seen,
under what circumstances and for
which conditions.
Many in Congress are already
convinced that Medicare should
continue the current coverage.
“The Covid-19 pandemic has been
a trial by fire, but the experience
to date has made clear that the
health care system is ready for
broader access to telehealth on a
permanent basis,” said Sen. Ron
Wyden of Oregon, a Democrat
who introduced legislation earlier
this month.
On Thursday, Sen. Lamar Alex-
ander of Tennessee, a Republican
and chair of the Senate health
committee, introduced the Tele-
health Modernization Act, which
would also make some changes
permanent. The experience of theprevious four months “will likely
mean that hundreds of millions of
physician-patient visits will be re-
mote or online that were in-person
before,” he said.
Since May, nearly 20
telemedicine bills have been
brought to the House floor and
about the same number in the
Senate, said Miranda Franco, a
senior policy adviser for the law
firm Holland & Knight. She thinks
legislation will be passed by the
end of the year.
While some lawmakers favor
permanently expanding Medi-
care payment for a broad range of
telemedicine services, others are
concerned about the technology’s
cost and potential for fraud. “Now
you’re talking about reimbursing
services we haven’t reimbursed
before,” Ms. Franco said.
Some patients say telemedicine
is not a substitute for in-person
care. Jorge Cueto, who is in his
mid-20s, said a virtual visit is of-
ten an additional step before go-
ing to the doctor’s office for, say, a
sore throat.
“It’s another fee, it’s another
gating mechanism,” he said.
His parents, who are not fluent
in English, prefer going to the doc-
tor’s office because they find it
easier to communicate in person,
he said, and they have difficulty
setting up video calls. “I don’t
think they would be willing opt for
telehealth if they weren’t required
to do it,” Mr. Cueto said.
Others may not have access to a
computer or smartphone to con-
nect for video visits, and insurers
are particularly wary of doctors
charging for phone calls to follow
up on lab results or tell someone to
come to the office.
Even patients who have cell-
phones may not be able to afford a
lengthy consultation, Dr. Levy
said. She and her colleagues dis-
covered some people stopped an-
swering their phones at the end of
the month because they had run
out of minutes. “That was very
eye-opening to us,” she said.
Some proponents argue the
goal of telemedicine should not be
to lower health care costs overall.
One of its main benefits is improv-
ing patients’ access to care, said
Dr. Ateev Mehrotra, a professor of
health care policy at Harvard
Medical School, adding that it
would be foolish to expect savings
if more people also get treatment.
“Those don’t reconcile,” he said.
Insurers should evaluate
whether telemedicine is more ef-
fective for treating conditions like
depression than it is for, say, can-
cer. They could then make those
distinctions in reimbursing for
virtual visits, he said, just as they
do for different prescription
drugs.
“There should be no single
telemedicine policy,” Dr. Mehrotra
said.VIRTUAL CARE
Will Shift to Telemedicine
Stick After the Pandemic?
Dr. Meeta Shah taking telemedicine calls at Rush University Medical Center in Chicago in March.DANIELLE SCRUGGS FOR THE NEW YORK TIMESDr. Donnie Aga, right, oversees telehealth at Kelsey-Seybold in Houston, which has seen telemedicine rise and fall in waves since the
pandemic began. While David Collins, left, said he appreciated the ease, “if you break your arm, an e-visit isn’t going to help you at all.”CALLAGHAN O’HARE FOR THE NEW YORK TIMES CALLAGHAN O’HARE FOR THE NEW YORK TIMESBy REED ABELSONWidespread adoption
could be hamstrung
by the potential cost.
MOSCOW — Russia plans to
start a nationwide vaccination
campaign in October with a coro-
navirus vaccine that has yet to
complete clinical trials, raising in-
ternational concern about the
methods the country is using to
compete in the global race to in-
oculate the public.
The minister of health, Mikhail
Murashko, said Saturday that the
plan was to begin by vaccinating
teachers and health care workers.
He also told the RIA state news
agency that amid accelerated
testing, the laboratory that devel-
oped the vaccine was already
seeking regulatory approval for it.
Russia is one of a number of
countries rushing to develop and
administer a vaccine. Not only
would such a vaccine help allevi-
ate a worldwide health crisis that
has killed more than 680,000 peo-
ple and badly wounded the global
economy, it would also become a
symbol of national pride. And
Russia has used the race as a
propaganda tool, even in the ab-
sence of published scientific evi-
dence to support its claim as a
front-runner.
“I do hope that the Chinese and
the Russians are actually testing
the vaccine before they are ad-
ministering the vaccine to any-
one,” Dr. Anthony Fauci, director
of the National Institute of Allergy
and Infectious Diseases in the
United States, warned a congres-
sional hearing on Friday.
State television in Russia has
for several months now promoted
the idea of Russia leading the
competition. In May, a govern-
ment report claimed that the first
person in the world to be vacci-
nated against the virus was a Rus-
sian researcher who had injected
himself with a vaccine early in the
development process.
Russia will start Phase III trials
of the vaccine in early August,
said Kirill Dmitriev, a senior offi-
cial with Russia Direct Invest-
ment Fund, a government-con-
trolled investor in the country’s
vaccination effort. A Phase III
trial is the only way to determine if
a vaccine is effective.
The World Health Organization
maintains a comprehensive list of
worldwide vaccine trials. But
there is no Russian Phase III trial
on the list.
Still, a Russian regulatory
agency is expected to approve the
vaccine this month, Mr. Dmitriev
said. That is far earlier than time-
lines suggested by Western regu-
lators, who have often said a vac-
cine would become available no
sooner than the end of the year.
“We believe it will be one of the
first vaccines with regulatory ap-
proval,” Mr. Dmitriev said.
But with limited transparency
in the Russian program, separat-
ing the science from the politics
and propaganda could prove im-
possible. Critics have already
drawn attention to Russia’s tradi-
tion of cutting corners in research
on other pharmaceutical products
and accusations of intellectual
property theft.
The U.S., Canadian and British
governments have all accused
Russian state hackers of attempt-
ing to steal vaccine research, cast-
ing a shadow over Russia’s claim
to have achieved a medical break-
through. Russian officials have
denied the accusation and say
their leading vaccine is based on a
design developed by Russian sci-
entists to counter Ebola years
ago.Russia was once at the forefront
in virology and vaccinations. In
the Soviet era, its doctors led the
world in some areas of research,
but spending has shriveled in re-
cent decades. Medicines are
sometimes approved with limited
or no testing.
Russian researchers have con-
tinued to advance a range of vac-
cines since the beginning of the
pandemic. The candidate to be
given in October is similar to a
vaccine developed by Oxford Uni-
versity and AstraZeneca.
The Russian vaccine was devel-
oped by the Gamaleya Institute in
Moscow. It uses two strains of ad-
enovirus that typically cause mild
colds in humans. Adenovirus vac-
cines are in trials in various coun-
tries. They are genetically modi-
fied to cause infected cells to make
proteins from the spike of the new
coronavirus.
The Gamaleya Institute tested
its vaccine on soldiers, raising eth-ical questions about consent,
though the defense ministry said
all of the soldiers had volunteered.
The institute’s director, Aleksandr
Gintsberg, went on television in
May to say he tried the vaccine on
himself before announcing the
completion of trials in monkeys.
“There is an escalation in the
geopolitics of vaccine research,”
said Cliff Kupchan, chairman of
Eurasia Group, a risk consulting
firm. But “what remains of the
vast scientific complex of the Sovi-
et period is a shadow of what it
was,” he said.
Countries with vaccine produc-
tion capacity — abundant in Rus-
sia and India — could wind up in-
oculating their populations by
copying a successful vaccine,
even if they did not in fact develop
it. In April, the Serum Institute in
India announced that it had plans
to mass-produce a vaccine, with
permission from the developer,
before clinical trials had ended.“In all likelihood, the country
producing on their soil will be the
first to get it, even if they don’t
own it,” Mr. Kupchan said. “I don’t
know how much international law
and patent protection will apply
here. People are pretty desper-
ate.”
Mr. Dmitriev, of the Russia Di-
rect Investment Fund, has attrib-
uted Russia’s research success to
the Soviet Union’s once-formida-
ble scientific study of viruses.
“We have this very significant
legacy of Russia being a leader of
vaccines in the Soviet time and to-
day,” he said. “We don’t have to
create many things from scratch.”
He contrasted that history with
Trump administration’s Opera-
tion Warp Speed program, which
is financing experimental re-
search by Pfizer and Moderna for
a genetic vaccine.
“In the last 20 years, the world
took a turn toward molecular biol-
ogy,” said Aydar A. Ishmukhame-
tov, the director of the Chumakov
Institute, a Russian vaccine
maker. “The Russian school has
preserved virology.”
Russia also has an advantage,
Mr. Ishmukhametov said, in its
vast, Soviet-era industrial base for
growing viruses for vaccines. In
the pandemic, the country has
turned to a secretive laboratory in
Siberia with roots in the Soviet
Union’s biological weapons pro-
gram, which included the study of
anthrax to target humans and
plant pathogens that would de-
stroy American crops.
The laboratory, Vektor, is now
testing whether viruses that
cause influenza or measles can be
put to use for a coronavirus vac-
cine.
The science of mass producingvaccine have deep roots here.
Aleksei Chumakov, a virologist
and son of the founder of the Chu-
makov Institute, recalled a sum-
mer job he held as a teenager
chopping up kidneys harvested
from African green monkeys.
Even though the monkeys had
been slaughtered, Mr. Chumakov
said, their kidney cells lived on for
many months, used to grow the
polio virus in large, rotating glass
cylinders.
As scientists gained proficiency
in growing so-called immortal cell
lines they replaced cultures from
fresh monkey kidneys.
The Chumakov Institute has
used an immortal monkey kidney
cell line from 1962 to grow coro-
navirus for a proposed vaccine.
The Gamaleya Institute devel-
oped its vaccine using a human
cell line first cultured in 1973,
known as Hek293 — the same line
used in the Oxford-AstraZeneca
vaccine. Like a number of other
cell lines used in medical re-
search, Hek293 began with cells
taken from an aborted fetus, rais-
ing objections from abortion oppo-
nents.
The first human cell line was de-
rived from the cancer that killed
Henrietta Lacks in 1951. HeLa, as
it was known, made its way into
Soviet laboratories during the
Cold War. Viktor Zuyev, an 91-
year-old emeritus professor of vi-
rology at the Gamaleya Institute,
recalled using it to cultivate flu vi-
rus.
He was unbothered by the ques-
tion of ethics.
“Why not?” he said. “It is very
humane to the next generation” to
use a dying person’s tissue for sci-
entific experimentation. “If it can
benefit humanity,” he said, “of
course it is ethical.”RACE FOR A CURE
Concerns Raised Over Russia’s Plan to Start Mass Vaccination in Fall
By ANDREW E. KRAMERA volunteer receiving a COVID-19 vaccine as part of clinical tri-
als at Sechenov First Moscow State Medical University in June.SECHENOV MEDICAL UNIVERSITY PRESS OFFICE, VIA GETTY IMAGES