A Rare Sign of Bipartisanship Progress: Telehealth in America

Amid COVID-19, Congress has an opportunity to move health care into the future by expanding access to telehealth services with bipartisan support.

by Arielle Kane, Progressive Policy Institute Director of Health Care

Over the August recess, I published a paper with Americans For Prosperity (shocking, I know) to highlight where there is bipartisan consensus on telehealth. Since the pandemic began, many telehealth regulations have been lifted and we explained what changes should be made permanent, what changes should go, and what additional policies could make care easier to access remotely.

Sen. Brian Schatz said that our paper demonstrated that, “telehealth is a rare area with strong bipartisan support and it’s here to stay. While we have made some progress in Congress on expanding access to telehealth during this pandemic, we have more work to do to make these changes permanent and allow more patients to continue receiving the critical health care they need wherever they are.”

I’ve summarized the findings below:

What policy changes have been made in recent months?

Federal Actions: In non-emergency times, Medicare’s ability to expand coverage to telehealth is quite limited. Services may only originate from inside an officially designated rural health professional shortage area, and from a statutorily allowed setting, which with very limited exceptions does not include the patient’s home. There are rules limiting what types of providers may deliver telehealth services, and requiring that telehealth be delivered by a real-time, two-way, audio-video connection. Other technologies, such as audio-only telephone calls and secure private emails, are not covered. Neither are asynchronous (store-and-forward) tools or remote monitoring of patients’ vital signs. On top of all this, the patient must have a prior existing relationship with the provider before he or she can use telehealth with that provider.

In late January of this year, after the federal Department of Health and Human Services (HHS) officially declared the spread of Covid-19 to be a public health emergency and Congress provided authority to waive statutory restrictions on telehealth during the pandemic, the Centers for Medicare and Medicaid Services (CMS) used those emergency powers to dramatically expand the telehealth services covered by Medicare and the digital platforms that may be used to provide care via telehealth. The agency also increased the amounts paid for telehealth visits and allowed providers to bill for services provided across state lines. Medicare officials also doubled the list of telehealth-provided services that Medicare will cover, including therapy services, emergency department visits, initial nursing facility and discharge visits, and home visits outside of rural shortage areas.

Under the CARES Act, Congress liberalized the statute governing health savings accounts (HSAs) to allow patients to receive first-dollar coverage of telehealth services (meaning without having to first meet a deductible) through the end of 2021.

State actions: Prior to the pandemic, almost all state Medicaid programs covered some telehealth services provided via live video; otherwise, state laws on telehealth varied dramatically. When the pandemic struck, all states eased at least some restrictions on telehealth, and 48 of them temporarily reduced some or all of their licensing requirements for out-of-state health care providers, making it easier for providers to treat patients across state lines.

Private payer actions: Many private insurers increased their coverage and reimbursement rates for telehealth services. Humana, for example, is waiving all copays for tele-primary care and tele-behavioral health visits for its Medicare Advantage members. Furthermore, many private health plans are voluntarily mirroring the government’s policies, or even going beyond them. Some states (California, for example) are pressuring private insurers to expand telehealth coverage, while others require them to do so.

Provider actions: Doctors and hospitals that have not previously offered telehealth services have been scrambling to adapt, both to make up for lost revenue as elective procedures have been put on hold and to safely maintain patient care. And some providers are restructuring their business models to make telehealth a permanent option for patients who pay out-of-pocket rather than through insurance.

Policies that Congress should make permanent after the pandemic:

  • Continue allowing patients to use telehealth outside of rural areas and at home.
  • Continue allowing providers to deliver care to both established and new patients.
  • Continue allowing licensed providers to practice across state lines. Federal legislation should empower providers to use their own location as the nexus in which care takes place for the purposes of payment — making treating patients across state lines more accessible.
  • Continue allowing health care providers to use store-and-forward technologies where medically appropriate.
  • Do not require payment parity for telehealth services versus those provided in person. To encourage telehealth adoption and to ease the financial strain of the pandemic, Medicare is currently reimbursing health care providers for telehealth services as if provided in-person. This makes sense during a public health crisis where the goal is to encourage telehealth use, but at other time there’s little reason to peg remote rates to in-person rates. Part of the promise of telehealth is that it can reduce costs. For example, when care is provided remotely, providers don’t have to clean exam rooms, waiting rooms, and other spaces. Reimbursement should reflect these savings.

Additional policies Congress should pass to increase access:

  • Expand broadband access. Except for audio-only (telephone) visits, telehealth requires fast and reliable broadband internet access. Though Congress and the Federal Communications Commission (FCC) have funded such access through the Covid-19 Telehealth Program and the Rural Digital Opportunity Fund, broadband connectivity still lags in some parts of the country. Structural changes, like reducing the bureaucratic and regulatory obstacles to getting more providers involved, will help more people realize the potential of telehealth.
  • Study the outcomes. HHS and the Agency for Health Care Research and Quality (ARHQ) should use the change in health care delivery as an opportunity to analyze the effectiveness of telehealth. It is important to study the effects of recent changes on utilization, access, and costs to inform future policy making. However, Congress should not allow the appropriate desire for further study to stand in the way of quickly implementing reforms that expand patients’ access to telehealth services.
  • Remove barriers to affordable care. The ultimate goal of all health reform efforts should be to ensure that everyone has access to the high-quality health care they need, when they need it, at a price they can afford. Telehealth can help with that, to be sure, but policy makers should also adopt sensible reforms that reduce costs and expand access to affordable care and coverage for everyone.

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