In March of 2020, the world suddenly started using telehealth. After decades of dragging their feet, providers implemented video visits and messaging applications overnight, and the public responded enthusiastically.
It is hard to believe that these advances could disappear in the United States, particularly when COVID-19 variants still swarm over us. Yet most of the changes came through regulations that were deliberately temporary and were never stabilized in law.
Of course, caution is commendable when issuing far-reaching emergency legislation. But now that telehealth has demonstrated its value, it’s time to make access universal and permanent.
I talked recently with Kyle Zebley, Vice President of Public Policy for the organization most active in telehealth policy, the American Telemedicine Association (ATA). He summarized how far the United States has come, which advances are threatened by the expiration of regulations, and the bills that the ATA supports to put telehealth on a firm footing. They have recently formed a group focused on Government Relations to create policy suggestions and help the ATA hold effective interactions with policy-makers.
What Are Clinicians and Patients Doing Now?
Zebley told me that the learning curve was fast and that clinicians on the whole have done an excellent job implementing telehealth at the beginning of the COVID-19 pandemic. Some 90% of patients report satisfaction with virtual visits, according to a survey of beneficiaries by the Medicare Payment Advisory Commission (MedPAC), an independent congressional agency.
Despite widespread alarm over the risks of fraud, the Department of Health and Human Services (HHS) has investigated telehealth and found that it’s no more prone to abuse than in-patient care. Telehealth can be more transparent, thanks to the digital records it produces.
Those who have been following innovation in medicine know that telehealth is a lot more than substituting video visits for in-patient ones. Effective telehealth is a combination known as connected health that combines continuous monitoring with interventions into patients’ daily behavior.
Most providers stick with the televisits, but the “hospital at home” can be found among some patients. According to Zebley, many payers, such as Medicare, are reimbursing remote monitoring for all patients with no geographic restrictions—and the number of patients who can take advantage of these policies now reaches into the millions. Of course, disconnected devices such as blood pressure monitors have long been used in the home. But more and more devices are connected and are recording sophisticated data (although one still has be careful when using the data for diagnoses, because the environment and the accuracy of devices vary a lot).
A few of the emergency changes that were made to regulations in 2020, enabling the new telehealth, include:
- CMS greatly expanded the number of services that could be delivered over telehealth, and the clinical settings that could offer it.
- CMS also allowed a doctor to treat a patient virtually without the complex requirements previously imposed, which required regular in-patient visits.
- CMS allowed patients to participate in visits from wherever they are located, including their homes. Strange as it seems now, CMS previously reimbursed telehealth only when a patient was already visiting a clinician (and it had to be in certain rural areas). This was not much of an imposition when the regulation was created in 1997, because few patients had broadband. In a parallel move, CMS allowed audio-only visits. Originally, services required video, which made sense because the visual medium conveyed much more information and the patient was assumed to be in a clinical office. But for people at home with possibly limited bandwidth, requiring video is burdensome.
- CMS (with permission from Congress) allowed providers anywhere to offer telehealth, which was previously limited to rural areas that lacked local clinicians.
- CMS relaxed its requirements for remote monitoring, thus making reimbursement easier.
The ATA wants to preserve and extend these changes, as we’ll see later.
When Should Visits Be Virtual?
The ATA believes that the clinician is the best person to decide when an in-patient visit should be necessary. The patient should also have the right to an in-patient visit if they want one. But clinicians have the expertise to know when they have to lay hands on the patient, and they live with the consequences if they make a mistake.
Thus, the ATA prefers that payers cover any virtual care determined by the doctor to be necessary. As fee-for-value replaces fee-for-service, payers will probably exert less fine-grained control over clinical decisions. Zebley said, “We oppose in-person requirements as a clinically inappropriate barrier to care.”
I asked Zebley whether doctors need more training to determine when a visit should be virtual or in-patient. He pointed out that the ATA was founded in 1993 and has provided guidelines. The Association of American Medical Colleges is adding training in telehealth to clinicians’ education.
Legislative initiatives
Many of the regulatory changes mentioned earlier in this article are expiring soon. It’s urgent to get Congress to act in order to allow all Americans to benefit from telehealth. And indeed, several bills are currently in Congress—with rare non-partisan support:
- Telehealth Modernization Act (S. 368, H.R. 1332)
- CONNECT for Health Act (S. 1512, H.R. 2903)
- Telemental Health Care Access Act (S. 2061, H.R.4058)
- The Protecting Access to Post-COVID-19 Telehealth Act (H.R. 366)
- Telehealth Extension and Evaluation Act (no number yet)
The provisions in all these bills overlap a lot, and all are supported by the ATA. The Telehealth Extension and Evaluation Act allows flexibilities to continue for two years after the end of the public health emergency. The other bills make the current telehealth rules permanent and give more leeway to HHS to allow telehealth. A couple other ATA goals include:
- Restoring rules that let high-deductive health plans provide telehealth, which could affect 30 million recipients. These rules were passed near the beginning of the COVID-19 shutdowns but expired in 2021.
- Allowing controlled substances to be prescribed through a virtual visit. Given the raging opiate crisis, this relaxation of rules may make some readers uneasy—but please remember that under-prescribing pain medication is also a big problem.
Actually, states regulate health care more than the federal government. Therefore, the ATA is active in all 50 states to expand telehealth, notably by allowing licensed doctors located outside the state to treat patients there. The existing mechanism for doing this is the “compacts” that states sign to allow doctors to register themselves and carry out some activities without having to go through the difficult process of obtaining a license in each state.
Basically, according to Zebley, “regulations should keep up with technical capabilities.” Everyone should have access to telehealth when it’s appropriate, regardless of location. The U.S. government also recognizes that many people need better Internet access in order to use telehealth, so there is action in the Administration, in Congress, in some states, and even by some payers.
Luckily, telehealth is non-controversial and is supported in principle by all the policy-makers that ATA has talked to. It is now supported by providers, payers, medical device vendors, pharma, academic institutions, and other companies in health care. Only a few providers seem to be stuck in the old ways. But to preserve and extend our gains, we have to overcome inertia.
