TIn the days before the COVID-19 epidemic, elehealth was a hugely popular option. Today virtual visits can be used for many medical services. However, this was made possible by the relaxed regulations of the government during the emergency. As the virus is beginning to loosen its grip over the United States now, medical organizations and telehealth companies are trying to make the pandemic-inspired changes permanent.
Congress extended many telehealth options for five more months, just five months after Biden’s Administration declared an end to the current public health emergency. This is due to expire April 16. Although it’s widely believed that President Joe Biden would extend the public emergency once more, there has been increasing pressure on him to end pandemic precautions. The congressional extension temporarily eases concerns about a “telehealth cliff” that could abruptly end coverage for virtual treatment, but telehealth lobbyists want to go further.
Telehealth advocates argue that regulatory changes have eliminated outdated and cumbersome restrictions and that telehealth expands patient access. However, some policymakers are still unsure of the quality and cost of telehealth, as well as the possibility of fraud with virtual care.
“Given how much we still do not know about telehealth with respect to cost, outcomes, quality— whether it is adding costs to the Medicare program or saving Medicare dollars—we believe it would be premature to make these expansions permanent,” says James Matthews, executive director of the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare. MedPAC will collect data in 2021 and 2022 so that it can study what “more of a steady state” of telehealth use looks like compared to 2020 when many people avoided leaving their homes, says Mathews.
Telehealth existed before the pandemic, but federal regulations “didn’t really allow for widespread use of the tool,” says Jacqueline Marks, a senior manager at Manatt Health. Medicare did not cover seniors living in remote areas who used telehealth to access their visits. This also made it harder for providers to offer telehealth. Providers were not paid the same as in-person visits for virtual visits. Because private insurers and Medicaid programs often follow Medicare’s lead, medical providers could only get reimbursed for telehealth visits in limited circumstances.
Telehealth usage soared after Congress relaxed these rules in 2020. According to the Department of Health and Human Services Office of inspector General, Medicare patients used Telehealth 88x more than before the pandemic. Telehealth claims by non-seniors increased and cash flow to telehealth businesses also rose. CB Insights reports that equity funding in telehealth was nearly $18 million last year. This is 57% more than 2020. “There is no doubt that telehealth saves lives,” Department of Health and Human Services Secretary Xavier Becerra said at a press conference this month. “We would be really closing our eyes to a new form of quality health care if we did not expand authorities for telehealth to be available to Americans.”
Telehealth enjoys rare bipartisan support, and has some strong champions in Congress. But with concerns about quality, cost, and potential fraud lingering, the industry is ramping up its lobbying efforts to make sure that its gains don’t slip away. Millions of Americans wonder what the future will hold for their healthcare.
“This has changed our entire healthcare ecosystem forever,” Marks says. “I think everyone’s just trying to figure out right now, how do we go forward?”
Vibin Roy is the Doctor on Demand Medical Director and speaks to patients during an April 2021 online primary visit from Keller Texas.
Telehealth advocates come from all sides, and they are pushing for Telehealth’s expansion in spite of Congress struggling to pass legislation amid fierce partisan divisions.
Democratic Senator Brian Schatz, from Hawaii, and Republican Senator Tim Scott in South Carolina are both advocates for bipartisan telehealth legislation. All stakeholders, including hospitals and physicians as well as non-healthy employers, want to see the telehealth system continue.
Traditionally, telehealth hasn’t had a unified lobbying powerhouse. While organizations such as the American Hospital Association and the American Medical Association spend millions of dollars annually to lobby on their favorite issues, the American Telemedicine Association only spent $120,000 last year.
These interest groups, however, have intensified their lobbying for telehealth in the wake of the pandemic. They are able to unite diverse factions around similar goals. They demand that the loosening of the Telehealth Rules be made permanent. Medicare must continue to pay for telehealth visits at a similar level to in-person visits. To extend coverage for video-only and audio-only visits and allow providers to work across state boundaries beyond the Pandemic, they should also keep the Medicare telehealth payments intact.
In December 2021 major players, such as AHA and AMA joined Teladoc and AARP to form a new coalition, Telehealth Access for America. The goal was to push for greater telehealth expansions. To increase advocacy, the American Telemedicine Association, also part of this coalition, created its own advocacy arm named ATA Action in January. Kyle Zebley, executive director of ATA Action, said the group’s lobbying footprint will grow this year as it coordinates priorities among those with wide ranging interests. “You can expect us to be significantly more invested in the direct technical lobbying efforts,” he says.
There are many challenges ahead
While telehealth is being supported, experts in the industry and legislators are wary about making drastic changes to American doctors’ practices without additional data.
Experts want to assess the quality of telehealth care. “What has been the impact on quality? Are there any issues? Is it affecting quality? We don’t really know,” says Ateev Mehrotra, associate professor of health care policy and medicine at Harvard Medical School.
In addition to giving Congress a five-month extension for telehealth reforms, MedPAC was also instructed to examine telehealth expansion. The commission is planning to address quality questions as part its work. Mathews states that MedPAC plans to examine how telehealth impacts patient outcomes. They will compare the hospitalizations in 2019 and those of emergency departments visits in 2022, and 2023.
Telehealth would be required to collect this information for at least a year beyond the end of any public health emergency. MedPAC’s report is due in June of 2023, but MedPAC favors a temporary extension for at least that time rather than permanent rule changes. If Congress continues temporary extensions until then, that could be “frustrating” for telehealth companies and providers, says Thomas Ferrante, a health care lawyer at Foley & Lardner and a member of the firm’s telemedicine team. “That’s very hard for long term planning, it’s very hard for an allocation of capital resources. And it’s hard to really message to your patients,” he says.
Telehealth advocates believe that the demand for faster data must be balanced against the need for greater information. “What we don’t want to do is study this thing to death and leave people out, forget the human component, tell the people who are using it, who are benefiting from it, that they have to sit on the sidelines while we crunch some more numbers,” says Claudia Tucker, senior vice president of government affairs at Teladoc.
Also, cost concerns can be a problem. MedPAC is researching whether telehealth is taking the place of in-person visits, or if it’s supplementing them, which could add costs to the government program, Matthews says. MedPAC will be investigating fraud possible in the telehealth services for Medicare beneficiaries.
Concerns were also expressed by other congressional advisors. According to the Congressional Budget Office, December 2020 found that removing geographic limitations for coverage of mental healthcare via telehealth would cost Medicare. The Government Accountability Office also told the Senate Finance Committee last spring the expansion of telehealth could result in higher fraud and costs.
But even if the public health emergency and its flexibilities end this year, the telehealth advocates see Congress’ five month extension as a chance to keep making their case in every way they can. Amwell Health Care has done polling on consumer interest in Telehealth. Teladoc has reported that Amwell received requests from advocacy groups to expand telehealth policies.
“People have tasted what it feels like when health care can work on their own terms in their environment,” says Dr. Roy Schoenberg, president and CEO of Amwell. “Because these technologies so profoundly changed the experience of the American patient, I think this is a very, very different kind of dynamic. I don’t think you can stop it at this point.”
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