Six years after the COVID pandemic, the virtues of remote health care are clear: Allowing patients to visit with their providers via phone or video call often means better access to health care for patients, including those in rural communities and those who struggle to leave their homes.
But the laws that regulate telehealth, as it’s known, have not kept pace with its rise and demand – at least not in the form of comprehensive legislation. Since the pandemic, Congress has funded telehealth largely on a stopgap basis, temporarily extending COVID-era flexibilities more than a dozen times in the last few years. Each time, the extension provides only temporary funding to the Centers for Medicare and Medicaid Services – the nation’s largest funder of telehealth services.
The newest deadline for Congress to act on telehealth policy – the 15th deadline set on this issue since the COVID pandemic – is Jan. 30.
Tara Sklar
Tara Sklar is faculty director of the Health Law and Policy Program at the James E. Rogers College of Law. In a recent perspective article in the New England Journal of Medicine, Sklar and her co-author, George Washington University’s Barak Richman, argue that the temporary funding measures for telehealth are not helping patients.
In this Q&A, Sklar, who is also associate director for telehealth law and policy at the Arizona Telemedicine Program in the College of Medicine – Tucson, explains what’s at stake with the newest funding deadline and potential pathways toward more comprehensive federal telehealth policy.
Q: What’s at stake if this deadline comes and goes with no action from Congress?
A: What makes telehealth accessible is that you can do it from your home – or, really, a patient could do it from anywhere. So, first and foremost, if the waivers don’t come back into place, it would restrict telehealth to certain geographic areas, where it has to be a rural area or an area with a health professional shortage. Medicare beneficiaries who don’t live in those geographic areas will not be covered by Medicare for telehealth services.
Providers also have to set up their telehealth workflow to accommodate patients, some they’re seeing in person, some they might be seeing on telehealth, and others in a hybrid format. So suddenly, if half of their Medicare reimbursement vanishes or is at risk, then it creates a lot of upheaval in terms of scheduling, what to do, how to see patients, and most importantly, how to maintain continuity of care.
Q: What is payment parity and how does it affect patients?
A: Payment parity is where a provider would receive the same amount of reimbursement for a telehealth visit as they would for an in person visit, and it currently is how Medicare reimburses for telehealth. There have been separate bills – one going all the way back to 2016 even – to help make these flexibilities with telehealth more permanent, so that patients could just call their doctor and not worry about whether Medicare is going to cover the visit.
Q: Why is it such a thorny issue for Congress?
A: The Congressional Budget Office has a really high price tag associated with these telehealth visits. They say it’s going to cost the Centers for Medicare and Medicaid Services as much as $4 billion over the next two years if we renew these waivers because people will get care perhaps more frequently. Many have also made the argument that patients are getting care in a more timely manner, so it’s saving costs later on, meaning that it’s still high-value care.
But I think the reality is – and why I co-authored the piece – is that we have to separate out these telehealth flexibilities from the overall budget appropriations bills. Otherwise, it seems likely that there will continue to be potential government shutdowns and these impasses disrupt care, and the Medicare telehealth flexibilities are a victim of that. There’s a ton of bipartisan support, just not enough to justify $4 billion a year over the next few years for these flexibilities.
Q: What other options for funding telehealth are available?
A: One outcome of this paper is from a group of providers, and they had this great quote: “Payment parity is the bridge not the destination.” They want to get a better sense of how much it actually costs to deliver a telehealth service with comparable in-person service, then create an overall amount of the cost differences and identify where there could be cost-savings while supporting better health outcomes. It’s just so incredibly reasonable. So, that’s one example of a group that hopes to see what integrated care (e.g., in-person care and telehealth care) would actually cost.
The other thing to think about is just looking at the states themselves. Half the states don’t have across-the-board payment parity – but those states might have payment parity for some types of services, such as behavioral health, primary care, or certain chronic conditions. They pick and choose the major issues of their state or their provider shortage areas so that those doctors have the incentive to treat patients no matter what. Other states pick and choose based on telehealth modality, so some have payment parity for live video, for example, but not for audio-only unless it’s a behavioral health appointment. In other words, there are variations across the country that could be explored to find preferred payment models to support permanent telehealth.
The fear with payment parity – and this is the whole bridge idea – is that if you don’t offer same amount of money, then providers won’t offer the telehealth option. And that just simply isn’t the case. Studies have shown a modest difference in terms of what payment parity is doing in terms of providers offering telehealth services, and especially going forward, as the Centers for Medicare and Medicaid Services is moving more towards value-based care. I think that incentive is going to fade as offering telehealth services is going to be expected as more patients demand it.
Q: What’s the human cost of not having comprehensive telehealth policy?
A: The stories that break my heart are the ones where a Medicare beneficiary has dementia and getting out of the house for a 15-minute visit is just harrowing. I worked with a geriatrician at the University of Virginia on a blog post, and in it, she describes what it’s like to go to see the doctor if you’re older and live either in a rural area or have any kind of severe cognitive impairment. It’s not just the Medicare beneficiary – it’s their loved ones, it’s their time away from work, from caring for children, it’s time away that is not easy to find. So, it’s not just about the 25% Medicare of beneficiaries who use this. There’s 65 million unpaid family caregivers in the U.S. Why would we make their job any harder?
SOURCE: https://news.arizona.edu/news/u-expert-urges-more-comprehensive-telehealth-policy
By Kyle Mittan, University Communications