Renewed discussions this week surrounding the next wave of relief efforts for COVID-19 have also reignited discussions surrounding telehealth. Telehealth is the use of technology, including interactive telecommunication, to deliver medical and other health services via virtual platforms. The CARES Act appropriated $200 million to help expand telehealth, but some say more is needed. The latest bill proposal from House Democrats does not include any additional funding for telehealth, but a bipartisan group of senators, led by Brian Schatz (D-Hawaii), is urging congressional leadership to reconsider. The coalition is calling for an additional $2 billion in funding to bolster broadband adoption — a prerequisite for most telehealthcare.
The initial relief package, passed through Congress and signed by the President in March, lifted a number of limitations on telehealth, expanded services eligible for reimbursement, and removed licensing restrictions in addition to the new funding. These efforts are ultimately intended to give care providers more flexibility and autonomy in delivering needed services for sick patients while reducing unnecessary risks. They also underscore the cost and difficulty of scaling up telehealth services quickly.
In recent years, patient access to telehealth services has been expanding. Some of the benefits of these expansionary efforts are straightforward. Providers and patients can schedule appointments in a more streamlined process and patients do not have to spend time in waiting rooms. Providers may find that utilizing telehealth services allows them more autonomy in their schedules, opening up possibilities to serve more patients at lower costs, especially if using mid-level practitioners. Since 2017, nearly all states provided some coverage of telehealth through Medicaid. Medicare also reimburses telehealth services.
In light of the COVID-19 pandemic, telehealth offers solutions in providing needed care for patients while mitigating many of the risks associated with a sick patient physically entering a medical facility. The advantages of telehealth intuitively make sense: patients who potentially have the coronavirus can video conference their doctor — or a mid-level practitioner — to receive adequate guidance on best next steps of action. This would eliminate sick patient interaction with multiple other personnel.
As Ajit Pai, Chairman of the Federal Communications Commission — the government agency overseeing the COVID-19 Telehealth Program — noted,
“Telehealth has emerged as a critical service for health care providers and patients alike during the coronavirus pandemic. It promotes social distancing, protects the safety of health care professionals and patients, and frees up space in health care facilities for those who now need it most.”
Receiving high quality, clinically proven care through telemedicine does involve a complex set of federal and state regulations. However, policymakers have taken a number of steps to momentarily reduce or eliminate many of these rules to make it easier for people to receive healthcare during the pandemic. As we outline below, these changes should be a roadmap not for temporary changes, but for permanent methods of how to improve distributed healthcare here in the United States.
Challenges of Telehealth
In a world where electronic communication accounts for an ever-increasing share of human interaction, healthcare appointments have remained surprisingly face to face. Part of the reason for this, of course, is that the nature of providing healthcare is often much easier, and in some instances only possible, when done in person. But a number of regulatory barriers also exist which prevent healthcare providers from implementing telehealth technology.
One of the biggest impediments to effective healthcare, especially in telemedicine, is the differing regulation between states. As noted by the Center for Connected Health Policy, every single state differs in its approach to telehealth policy.
Differences in state-by-state licensing for physicians creates one of the largest impediments to increased telehealth implementation. These laws prevent doctors licensed in one state from providing medical advice to individuals living in a different state. For example, while a doctor may have studied in California, done her residency in Kansas, and currently be licensed in the state of Florida, she is only able to practice in one state: Florida. This nullifies one of the greatest advantages of telehealth: its ability to connect doctors and patients regardless of geographic distances.
This barrier also creates a huge financial risk for healthcare providers who want to invest in software for telehealth services. Currently, most states have adopted exceptions to licensing laws that allow any doctor licensed and in good standing in another state to provide telehealth services to patients across state lines. But once those exceptions are removed, investments made in telehealth technology will be stranded until doctors can get new licenses in states outside of their own.
For example, Presbyterian Medical Services provides healthcare to over 80,000 patients in New Mexico. In the wake of the pandemic, they have spent $25,000 on video-visit software for a portion of its providers. They estimate that to cover all 250 of their providers would cost $400,000 annually. Once state licensing exemptions expire, those doctors will once again be restricted to only serving patients in New Mexico, shrinking the size of their potential customer base and reducing the value of their investment.
In addition to differences in licensing requirements, states have different approaches to Health Information Portability and Accountability Act (HIPAA) requirements and patient privacy, drug prescription, and reimbursements. These require providers to implement different systems for each and every state they wish to expand to while also increasing the learning curve for physicians to operate legally and effectively. States’ efforts to standardize these requirements along with licensing standards would go a long way to improving the feasibility of telehealth services.
State governments aren’t the only institutions guilty of impeding telehealth expansion. Federal restrictions are creating their own share of problems. The biggest deals with restrictions on medicare reimbursements for services provided via telehealth. Current laws prevent the Centers for Medicare and Medicaid Services (CMS) from providing reimbursements for telehealth services unless the patient receiving the services lives in a Health Professional Shortage Area that exists outside of a Metropolitan Statistical Area. The intention of this rule was to make telehealth available to individuals living in rural areas with physician shortages, but it restricts a large number of Americans on Medicare from also benefiting from telehealth.
The restriction was put in place to prevent telehealth costs from straining Medicare budgets, but according to numerous studies, greater utilization of telehealth services may actually lead to massive cost savings. These savings come from a combination of more efficient services, reductions in transportation costs, and reduced visits to more expensive providers like hospital emergency departments. One study from the Center for Information Technology Leadership estimated that savings could be as large as $4.3 billion annually.
Congress momentarily waived these geographic restrictions with the passage of the CARES act in March. Just like the momentary changes discussed above, this is another great opportunity to make a permanent change to a harmful restriction. After all, if you receive the same care virtually that you would have received in-person, why should the reimbursement be any different? The benefits of telehealth could improve healthcare outcomes for all Americans, regardless of their physical access to physicians or their residence in urban or rural areas.
Improvements in Patient Satisfaction
Despite telehealth only accounting for a relatively small fraction of total healthcare visits, it has already had real impacts on patient care. For example, the Mayo Clinic conducted a review of the effectiveness of telehealth in prenatal care. In this study, 300 women with low-risk pregnancies were randomly assigned to either 12 planned office visits with a physician or midwife or to Mayo Clinic’s “OB Nest” model. This model consisted of 8 planned clinic visits with a physician or midwife, 6 virtual visits with a nurse, home monitoring with automatic blood pressure cuff and a hand-held fetal Doppler monitor, and access to the online prenatal community. The results show the effectiveness of telehealth. They found that the “OB Nest” model had improved patient satisfaction, decreased stress related to the pregnancies, and decreased office visits. In addition, they found no difference in “perceived quality of care, unplanned visits, maternal or fetal outcomes.”
These findings have since been echoed by studies done in the Department of Veteran’s Affairs health system. The VA runs one of the largest telehealth platforms in the nation and touts the success they have had with it. This network reports providing 2.17 million telehealth episodes of care to over 702,000 veterans. While providing high levels of patient satisfaction and no significant difference in health outcomes, this network has proven effectiveness in treating rapidly spreading diseases. In fiscal year 2016, the VA telehealth reported a “59% decrease in VA bed days of care and a 31% decrease in VA hospital admissions.”
Looking to the Future
With no significant differences in patient care, it is easy to see why providers are trying to quickly scale up telehealth services during the pandemic. Screening, diagnosis, and treatment can be achieved with fewer bed days and fewer hospital admissions. This means that there is lower exposure of the virus to healthcare providers and other patients. This could also allow providers the ability to focus more of their time on critical patients.
Telemedicine allows for quick shifts in the allocation of resources that simply aren’t possible with traditional medicine. As shortages of medical supplies and devices continue, being able to practice medicine without unnecessary face to face interaction has huge advantages, given that patients can receive the care they need without a doctor physically present. This pandemic has given the industry a look into how useful telemedicine can be without regulatory restrictions.
The CARES Act initiated a number of meaningful actions to expand telehealth availability. The benefits of removing many of these barriers during a time of crisis should not be quickly forgotten once life returns to normal. Lawmakers should consider the benefits of implementing these changes long-term so that technology can revolutionize the way we receive healthcare in much the same way it has revolutionized the way we work, play, and live.