THE UPHILL BATTLE OF TELEHEALTH ASSIMILATION

the uphill battle of TELEHEALTH ASSIMILATION BY MARK WENDLING, MD, EXECUTIVE DIRECTOR, VALLEY PREFERRED

Thank goodness for telemedicine. It was a lifesaver during the early stages of the pandemic, when patients needed to see their physicians but were locked down at home. As cautionary measures change, it still offers safety and convenience, especially for those who live distantly from their health care providers. However, its fate is up in the air depending on the life span of the health emergency status telehealth has been given due to COVID-19.

As of March 2022, the public health emergency status is still in place. But those in the industry caution that if that statute is lifted, for many, telehealth coverage will just end. People living in rural areas wouldn’t be able to use computers in their homes but would have to go to an authorized center for access. While we can’t predict the direction the industry will take, we can review the issues, understand the complexities of extending coverage, and explore some actions already in progress.

THE CURRENT STATUS WITH INSURERS AND REIMBURSEMENT

So far, there has been a hunt-and-peck approach to extend and broaden reimbursement for telehealth, which would ensure providers can continue to offer the service to patients. CMS’s Calendar Year 2022 Physician Fee Schedule final rule, approved in early November, will promote greater use of telehealth for behavioral health care services, diabetes prevention, and vaccine administration. The final rule also advances programs to improve the quality of care for people with Medicare by incentivizing clinicians to deliver improved outcomes.(1)

However, there are caveats to coverage under Medicare as well as Medicaid. This is an excerpt from the Pennsylvania Department of Human Services Sept. 30 Medical Assistance Bulletin:

In response to CMS’s policy changes during the COVID-19 PHE, the Medical Assistance (MA) Program has allowed for audio-only services in situations where the beneficiary does not possess or have access to video technology and when clinically appropriate. The Department will continue to allow providers to utilize audio-only telecommunication when the beneficiary does not have access to video capability or for an urgent medical situation, provided that the use of audio-only telecommunication technology is consistent with state and federal requirements, including guidance by CMS with respect to Medicaid payment and OCR with respect to compliance with Health Insurance Portability and Accountability Act (HIPAA).

For the most part commercial payers are following in the footsteps of CMS, although some have added waivers, are allowing additional services, and disallowing others. For example, some payers do not pay for remote patient monitoring (RPM), while Medicare does. Many of the commercial insurers allow virtual check-ins as long as the Public Health Emergency (PHE) is in effect. The current PHE was recently extended to April 16, 2022, and organizations such as

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the Federation of American Hospitals is urging the date be extended further.

“Regarding Medicare, there are numerous bills pending, such as Bill S.1512 and H.R.2903 (CONNECT for Health Act of 2021), which would allow CMS to waive certain restrictions, such as the types of technology that can be used; permanently remove geographic restrictions; allow the home to serve as an originating site; permanently allow FQHCs and RHCs to serve as a distant site; and allow CMS to generally waive coverage restrictions during any PHE,” says Joseph Tracy, MS, BA, Vice President – Connected Care and Innovation at Lehigh Valley Health Network. “These bills were introduced in April 2021, but we don’t know when the Senate or House will vote on them.

“It’s always been an uphill battle,” continues Tracy. “When Medicare became law in 1965, nobody dreamed doctors would be seeing patients virtually. The laws essentially have to be rewritten. You could say that telehealth is just part of health care now, and we’ll pay for it like any other service. But where does the money come from?”

STATE LICENSING ADDS A LAYER OF COMPLICATION

The pandemic altered the previously standing law that forbid physicians and other health care practitioners to provide care to patients out of state without obtaining a medical license in that state. There have been attempts at keeping the momentum going. For example, a bipartisan group of lawmakers reintroduced the Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act (S.168, H.R. 708) on Feb. 2, 2021, which would provide temporary licensing reciprocity for health care professionals for any type of services provided to a patient located in another state during the COVID-19 pandemic. However, the act remains in limbo at this writing.

That has left it up to individual states to tackle the problem, since providers want to be able to treat their patients and have access to their medical records wherever they may be traveling. Pennsylvania’s Governor Wolf granted a waiver to allow licensed practitioners in other states to obtain an expedited temporary license to provide services to Pennsylvanians via the use of telemedicine. That waiver is set to expire on March 31, 2022. Eighteen other states also issued waivers modifying telehealth requirements in response to COVID-19.

Interstate compacts (agreements between two or more states) have been proposed that make it easier for health care providers to practice in multiple states — expediting the licensing process or allowing members to practice under a single multistate license. Some of the larger compacts are backed by well-established regulatory boards. Many also meet the federal licensing requirements of the Centers for Medicare & Medicaid Services.

Those sitting on state licensing boards claim their regulations are put into effect to protect patients, referring to the trust and confidence in knowing the qualifications underlying one state’s license are on par with those of other states. Critics question that perspective and link it to the fees that licensing boards collect. As this controversy slogs on, medical practitioners are held uncomfortably in the middle, obligated to comply with diverse regulations should they want to care for patients in a state other than where they live and primarily practice. The outcome is not yet clear.

DOES TELEMEDICINE CUT COSTS AND IS THE TECHNOLOGY AFFORDABLE?

“It can cost less,” says Tracy. “For example, rather than moving a patient to a hospital where there is a particular specialist, if that patient can be seen and treated safely via video, you can drastically cut transport costs.” He also refers to cost reduction during the pandemic, when virtual Covid screenings kept patients from going to the higher-cost emergency department or urgent care route. “The principle is much like that in the ICU,” he says. “When we can treat patients and move them to a lower-cost environment rather than an ICU, we are reducing costs.”

The cost of telehealth could be more for small, independent practices who either need to set up a telehealth network of their own or contract with a vendor to provide those services. During the height of the pandemic, practitioners were able to use platforms such as Facetime® and Microsoft Teams®, which may have saved on expenses but are not necessarily secure. While Tracy notes that some practices are still doing it, “the majority of telehealth users accessed virtual care services through their regular physician or health plan, as opposed to direct-to-consumer telehealth platforms,” according to new data from Morning Consult. “Of the nearly 2,200 survey respondents, 72% reported that they attended appointments through their physician or health insurance, while 17 percent said they used on-demand telehealth services.”

Some practitioners and health systems have had some help from the government to further education and application of telehealth. In August 2021, the Biden-Harris administration appropriated investments to strengthen telehealth services in rural and underserved communities and expand telehealth innovation and quality nationwide. These investments — totaling over $19 million — were distributed to 36 award recipients through the Health Resources and Services Administration at the U.S. Department of Health and Human Services.

Tracy says that while this support will certainly help, there are numerous points that need to be addressed to ensure telemedicine can deliver its full potential. “How do we decide how many cell towers to put up? Where do we put them? And what if the patient doesn’t have the technology to connect? These are all important questions,” he says.

USAGE OF TELEMEDICINE STILL STRONG

While one source puts usage at 38% higher now than before the pandemic, it notes that as cautions related to the virus ease, more people are returning to see their doctors in person. According to a survey recently conducted by The Harris Poll, roughly 65% of people plan to continue to use telehealth after the pandemic ends. If given the option between a telehealth visit or an in-person visit, relatively few respondents (15%) said they would opt for telehealth services alone. Most people (44%) still preferred in-person visits, but nearly as many

(42%) would choose a combination of in-person and virtual care.(2)

You have to look at the age groups to get a clear picture of acceptance and use of telehealth going forward. More than 70% of younger generations (Gen Z, millennials, and Gen X) said they prefer telehealth because of convenience. Gen Z and millennials are resisting a return to in-person care, with 44% saying they may switch providers if telehealth visits aren’t offered going forward. Meanwhile, only a quarter of baby boomer patients prefer telehealth to in-person care.(3)

“It’s natural for some people to pull back and want to see their providers in person, if they live close by,” says Tracy. “But for those who live a distance away, telehealth levels the playing field in terms of access to necessary health care services, which sometimes makes the difference between receiving or not receiving care.”

PROVIDERS WAITING FOR AN OUTCOME TO MOVE FORWARD

Some providers are voicing opinions about medicine moving toward a hybrid of both remote care — in the types of cases where that suffices — and in-person care. However, the more states hesitate on legislation and insurers remain undecided about coverage, providers are leery about how much their practices should invest in new or enhanced capabilities to offer telehealth appointments.

“There’s so much uncertainty about what’s going to be made permanent and what’s going back to the way things were,” says one physician. “Now, a lot of providers and even hospitals are asking, ‘Should we continue to invest in the infrastructure for this? Is our state going to continue to allow this or not?’”(4)

The bottom line: Telehealth is a technology and service that can help mitigate stress on the health care system, patients like it, and it broadens access for those who live distantly. Are these benefits alone — without a pandemic to push the issue — enough to motivate insurers to continue coverage and technology providers to step up expansion? The next few months will absolutely be critical in learning which way the wind will ultimately blow in the world of telemedicine and electronic access to care.

SOURCES

(1) https://www.cms.gov/newsroom/press-releases/ cms-physician-payment-rule-promotes-greater-access-telehealth-servicesdiabetes-prevention-programs

(2) https://medcitynews.com/2021/01/ poll-most-americans-plan-to-use-telehealth-after-the-pandemic/

(3) https://www.aha.org/aha-center-health-innovation-market-scan/202106-29-there-may-be-generation-gap-telehealths-future

(4) https://www.npr.org/sections/health-shots/2021/11/23/1056612250/ voice-only-telehealth-might-go-away-with-pandemic-rules-set-to-expire

ADDENDUM

As the Public Health Emergency changes, so will the accuracy of the information in this article. The following is an update as of March 15, 2022:

On March 15, President Biden signed the Consolidated Appropriations Act, 2022, an omnibus funding bill that includes government appropriations for fiscal year 2022 through September 30, 2022; $13.6 billion in aid for Ukraine; and an array of health policy provisions including Telehealth Flexibility Extensions under the Medicare Program. The bill temporarily extends the following, which enable Medicare beneficiaries to access a broad range of services via telehealth from any location, for 151 days beginning on the first day after the end of the public health emergency (PHE) period: • Any site in the United States, including a patient’s home, will be considered an eligible originating site for the delivery of telehealth services. • Facility fees will not be paid to newly covered originating sites (e.g., a patient’s home). • Eligible telehealth practitioners will continue to include qualified occupational therapists, physical therapists, speech-language therapists, and audiologists. • Federally qualified health centers and rural health clinics may serve as originating or distant sites for the delivery of telehealth services. • Providers will not be required to meet in-person visit requirements in order to deliver mental health services via video or audio-only visits. This applies to all sites of care, including Federally Qualified Health Centers and Rural Health Clinics (except in the case of hospice patients). • Coverage of telehealth services delivered via audio-only format will continue for specific service codes identified by Medicare as being eligible for delivery via audio only. • Practitioners will be able to use telehealth to conduct face-to-face encounters prior to recertification of eligibility for hospice care.

For more information, refer to the bill directly.

Telehealth Flexibility Extensions are found in

Division P, Title III, Subtitle A, pages 1901-1911.

https://rules.house.gov/sites/democrats.rules.house.gov/files/BILLS-117HR2471SA-RCP-117-35.pdf