Post-Public Health Emergency: Don’t Forget the Importance of Telehealth

The Department of Health and Human Services (DHHS) is expected to extend the Public Health Emergency (PHE) later this week, marking the 10th extension since the PHE was first declared in January 2022. This extension will be for at least another sixty days, consistent with the Department’s prior assurance to give states that degree of advance notice to facilitate the complicated transition to a post-pandemic world.

While we collectively look to a world on the other side of the Pandemic, there is no question that the experience of the past two years has changed many things. Not least being our expectations around the delivery and receipt of health care services: one of the most immediate being the exponential increase in telemedicine and telehealth services to meet patient needs during a time of social distancing and strained capacity. Last year, DHHS “crunched the numbers” and found a 63-fold increase in telehealth utilization by Medicare recipients alone.

This expansion in telehealth utilization was only possible due to the waiver of federal regulations restricted when and where Medicare (and to a lesser extent, Medicaid) services could be delivered. Those waivers, in the absence of legislative action, will expire following the end of the PHE.

For that reason, it is worth “looking back” on Medicare’s governing regulations relating to reimbursement for telehealth services.

MEDICARE TELEHEALTH REIMBURSEMENTS BEFORE COVID

Medicare Telehealth policy (when services can be delivered by telehealth) hinged upon four considerations:

1. the service provided;
2. what type of provider provides the service;
3. the modality used to deliver the service (i.e. real time video and audio, regulations requiring vaguely defined interactive component); and
4. the location of the patient at the time of the interaction.

Of these four components, the location requirement for delivery is the most restrictive; meaning that, absent the aforementioned PHE waivers, providers cannot collect reimbursement for services provided to Medicare patients in their home. Services could be delivered at another facility (such as a physician’s office or outpatient facility), but only in rural and non-metropolitan service areas.

The primary rationale for these restrictive reimbursement requirements is that of utilization – and ultimately that of cost-control. The Congressional Budget Office (CBO) estimates an increase in spending of $25 billion over ten years in the event PHE telemedicine waivers are made permanent.

However, prohibiting delivery of Medicare services to patients in their home precludes one of the most compelling elements of telehealth care delivery – the ability for patients (broadband and devices permitting) to receive care in a format and location that are most convenient to them.

Of course, there are a lot of challenges that come with telehealth delivery. The availability and reliability of broadband connections is not something we can take for granted. There remain substantial barriers to patients’ access to digital resources and their respective comfort and fluency utilizing the same, and then the perennial data privacy and security considerations that come with digital interventions. These are all areas requiring continued attention and investment from providers, technology platforms, and policy makers.

But the Pandemic presented a pretty unique (not so controlled) experiment in telehealth capabilities, their implementation, and consumer adoption. And for the most part, many patients – as consumers – are not looking back. Surveys have shown high patient satisfaction and trust in care delivered through telehealth applications; as reflected in one study evaluating provider-initiated telemedicine applications at an urban Academic Medical Center in Los Angeles County (82.7% satisfaction rate).

TELEHEALTH – LOOKING FORWARD

We have already made some progress as it relates to telehealth regulations. Earlier this year, as part of its Appropriation’s Bill, Congress mandated the extension of DHHS’s telehealth waivers for an additional five months after the end of the PHE. Furthermore, informed by the Mental Health Crisis, the continuing opioid crisis, and the maldistribution of mental health providers across the nation, Congress passed legislation over a year ago removing geographic and home exception restrictions for the provision of mental health and substance use disorder services. Going forward, patients may receive mental health services in their homes through telehealth provided that an in-person evaluation is conducted at least six months prior to the remote intervention.

But perhaps the most important outcome of the past two years is data. Prior to the pandemic, wide-spread utilization of telemedicine constituted an unknowable unknown. The CBO and other organizations charged with informing federal policy decisions, cited lack of data as one of the biggest barriers to estimating the impact amendment of telehealth restrictions would have on use, quality, access, and cost. In 2015, following Congressional hearings on telemedicine in Medicare, the CBO identified this deficiency, noting:

CBO’s analysis would benefit from having the results of new and well-designed academic studies examining how introducing telemedicine services would affect health care spending in the Medicare population. The results of a demonstration project conducted in the fee-for-service Medicare program could be especially valuable in light of the particular challenges of controlling spending on new benefits in that program.

Seven years and a pandemic later, we have that data – relying more on circumstances and less on the (sometime arid) world of well-designed academic studies.

We know that extending telemedicine access will result in increased costs and utilization (conservatively estimated at $25 billion over 10 years). But in that analysis are we accounting for improved quality? Availability? Value of services? Does that calculus include the cost and considerations that come with shifting our care delivery paradigm to be more patient-centered and value-oriented?

Speaking for myself, I have come to increasingly rely on, and expect, access to telehealth as a modality for receiving health services. It can’t do all things – but there is no question that removing the friction of distance, transit, juggling limited time between work, personal commitments, and the dreaded parking lot and doctor’s office waiting room expands timely access to health care. The latter point should not be underestimated: in most communities, a 20 minute visit to a doctor’s office requires allocating 2 hours. And I say this as a person living in a metropolitan area with immediate access to my primary care provider and the gamut of specialists. That is not the reality for many – and telemedicine is an important lifeline that we cannot hide back away in the back of our collective toolbox.