More Telehealth Data Urged Before Making Eased Rules Permanent

Congress should get a clearer picture of how patients use telehealth before making pandemic-inspired relaxed rules permanent, Medicare advisers say.

Lawmakers recently extended telehealth changes until five months after the end of the public health emergency is declared. This extension in the omnibus spending package eases telehealth advocates’ concerns about a “telehealth cliff,” or the abrupt cut off of coverage of most virtual care.

Many medical groups have called on lawmakers to make broader telehealth permanent because it increases health-care access and convenience. But concerns about quality, cost, and fraud keep lawmakers from moving forward on telehealth, which generally has bipartisan support.

“We hesitate to draw too many definitive conclusions” from data from 2020, “the year in which the entire health-care system was severely locked down,” said James Mathews, executive director of the Medicare Payment Advisory Commission, which advises Congress on Medicare. Once the commission has data from 2021 and 2022, “we’ll have a sense of what telehealth looks like in a more benign environment, a clearer picture of who’s using telehealth, and it’s implications on access to care,” Mathews said.

Telehealth wasn’t widely available before the pandemic because the Centers for Medicare & Medicaid Services would only reimburse visits that met a “perfect storm of criteria,” said Thomas Ferrante, a partner at Foley & Lardner LLP and member of the firm’s telemedicine team. Payment rules in the Social Security Act limit telehealth to patients who live in rural areas and initiate their visits in qualifying sites like hospitals. Only certain kinds of providers could deliver telehealth services.

The CARES Act, a cross-sector Covid-19 relief bill, allowed doctors to initiate telehealth treatment with patients in their home during the public health emergency. Medicare beneficiaries used telehealth 88 times more during the first year of the pandemic than they used it the year before, according to a report from the Department of Health and Human Services Office of Inspector General.

The pandemic led to an “involuntary laboratory experiment” testing the utility of telehealth, which never would’ve seen such widespread adoption without the reimbursement flexibility, Ferrante said.

Benefits

Democrats and Republicans in Congress support telehealth because it has increased access to care for their constituents, particularly in the early days of the pandemic when people were hesitant to receive in-person care.

Over 28 million Medicare beneficiaries used telehealth in the first year of the pandemic—more than 2 out of 5 beneficiaries, according to the OIG report.

Telehealth can encourage people to access necessary care when they would otherwise put it off because of a long commute to a doctor’s office, said Krista Drobac, a partner at health-care consulting firm Sirona Strategies and executive director of the Alliance for Connected Care. The modality is ideal for post-acute care check-ins and chronic disease management, she said.

“There’s also cost savings in places like nursing homes,” Drobac said. “Instead of putting a patient in an ambulance and sending them to the hospital, a telehealth provider can actually address more issues on site.”

The five-month extension in the omnibus package “provides certainty not only to providers on what they’re able to do, but also to patients that they’re still able to receive some of these services through these modalities,” said Mei Kwong, executive director of the Center for Connected Health Policy.

“As patients take advantage of these changes and health access is broadened, we are hopeful that Congress will see the wisdom of making these changes permanent,” Gerald Harmon, president of the American Medical Association, said in a statement.

“There is no doubt that telehealth saves lives,” HHS Secretary Xavier Becerra said at a recent press conference. The HHS is “going to work as aggressively as we can to get as much authority as possible,” he said.

Hesitations

Data on the quality of care and patient outcomes for remote versus in-person treatment “would be essential to discussions about making any or all of these waivers permanent,” Mathews said. MedPAC is going to work on comparing population-level data on hospitalizations and emergency room visits from 2019 to 2022 and 2023, once telehealth “has become stable,” to see whether those visits could have been avoided due to the presence of telehealth, Mathews said.

In order to get clear data, lawmakers would need to keep telehealth around for at least a year after the public health emergency, Mathews said.

Advocates say the data on quality is already clear. “We are providing the same, and in some cases, enhanced care when we are meeting patients where they are,” said Shabana Khan, a child and adolescent psychiatrist and member of the American Psychiatric Association’s committee on telepsychiatry.

Cost is also a barrier to passing more permanent legislation. “It’s expensive to deliver telehealth, and so I think there is concern about the financial impact to the Medicare program at large,” said Claire Ernst, director of government affairs for the Medical Group Management Association. If people who otherwise wouldn’t have gotten care do via telehealth, it’s more taxing on the program.

More data is also needed to assess whether patients follow up a virtual visit with an in-person visit, increasing costs, Drobac said.

Fraud is always a concern for the Medicare program, and some lawmakers may be wary that fraud is easier to commit virtually, said Morgan Reed, executive director for the Connected Health Initiative. Digital medicine has actually “reduced the amount of fraud because there are better fingerprints” like length of visit and IP address than physical records, Reed said.

Future Action

Providers are investing in telehealth, which will likely grow irrespective of the future of Medicare reimbursement. “The consumer demand is there now,” Ferrante said, and some telehealth provider pricing is more competitive than a patient’s copay.

But “they would certainly invest more” if they knew how long the flexibility would last, Ferrante said. “Why invest when you don’t know if the service you’re providing today is going to get paid for tomorrow?”

The omnibus package requires MedPAC to study expanding telehealth services, which would mean amending the Social Security Act, Ernst said. The report is due June 15, 2023. A separate HHS OIG report on fraud prevention measures is due on the same day.

Congress could keep offering temporary telehealth waivers through that due date, particularly if lawmakers’ decision making depends on MedPAC’s and OIG’s analysis, Drobac said.

The five-month extension “is enough time to really continue to work with our bipartisan champions in both the House and the Senate and the administration to make sure that Congress acts again,” said Kyle Zebley, vice president of public policy at the American Telemedicine Association.