If you had told me at the beginning of last year that the total annual revenue of U.S. telehealth would increase from about $3 billion to potentially $250 billion in 2020, I think I would have asked that you had your head examined, and I don’t mean over video! But with the COVID-19 pandemic, we have seen telehealth move from being a peripheral health care service option to being the preferred option for millions of Americans to receive their care during this challenging time. Telehealth has allowed for continuity of medical care during the pandemic, and telehealth has also expanded in various ways to make it easier for people to receive specialty care services like behavioral health, without the need to visit a doctor’s office. Although telehealth has been around for decades, to say that telehealth catapulted into the national spotlight in 2020 would not be an understatement.
As someone who has been in the telehealth field for the past four years, I have been astounded at just how much the telehealth landscape changed this year, and at how complicated it has become. With the onset of COVID-19, health care systems and practices accomplished in a matter of days what otherwise would have taken weeks, months, or even years, as thousands of medical staff and administrators were trained on implementing telehealth and creating and learning new tasks, protocols, and workflows to support telehealth’s adoption as quickly as possible. This hard work paid off as the CDC reported that telehealth visits increased 154% during the last week of March 2020, compared with the same period in 2019. By April, in-person visits to physician offices and other health care practices fell 60%, while telehealth visits accounted for nearly 69% of total health care encounters. Health care providers are delivering approximately 50-175 times more telehealth visits than they did pre-COVID-19. Yes, the “new normal” for telehealth is indeed here, but what exactly does that mean?
Well, it’s complicated. Let me explain. The main reason that telehealth was able to move to the forefront of health care delivery this year was not necessarily because of the COVID-19 pandemic itself, but rather it was due to the telehealth policy changes that came as a result of the pandemic. Back in March, when a national emergency was first declared, additional leeway was given to federal and state agencies to respond to the crisis, and they did so. The Centers for Medicare and Medicaid Services (CMS) greatly expanded Medicare’s telehealth benefits, for the first time allowing Medicare beneficiaries to receive many services via video and phone, waiving the need for a pre-existing relationship, and allowing for telehealth services to be received directly in a patient’s home. Medicare also specified that providers could bill for telehealth visits at the same rate as in-person visits, which is known as telehealth “parity.” Also in March, The Office for Civil Rights (OCR) relaxed its enforcement policy and stated it would waive potential HIPAA penalty violations if previously noncompliant video apps, like FaceTime and Skype, were used to deliver telehealth. Of course, there were many more telehealth policy changes implemented on the federal level, way too many to list here, but some of these, along with some of the changes we just reviewed, are temporary and are tied to the public health emergency (PHE). CMS recently published their 2021 revisions to the Physicians Fee Schedule (PFS), making some of the temporary changes permanent, but there are still services set to expire at the end of the year the PHE ends. See what I mean? Complicated.
I hate to complicate things even more, but as we discuss the telehealth policy changes at the state level, I’m afraid that may be inevitable. One of the more interesting, and frustrating, things about telehealth is that it is defined and legislated different in every state. This means that, at the state level, and especially for Medicaid populations, telehealth policy and reimbursement look different, and the types of telehealth services that are covered could vary greatly from one state to another. Colorado has been at the forefront in making some of these temporary telehealth policy changes permanent as Governor Polis signed Senate Bill 20-212 into law on July 6, 2020. The bill prohibits Division of Insurance-regulated health plans from:
- Placing specific requirements or limitations on the HIPAA-compliant technologies used to deliver telehealth services.
- Requiring a person to have an established relationship with a provider in order to receive medically necessary telehealth services from that provider.
- Mandating additional certification, location, or training requirements as a condition of reimbursement for telehealth services.
For the Colorado Medicaid Program, Senate Bill 20-212, makes a couple of important policies permanent. First, it requires that the state department reimburse rural health clinics, the Federal Indian Health Service, and Federally Qualified Health Centers for telehealth services provided to Medicaid recipients at the same rate as when those services are provided in person. This is a huge shift for Colorado Medicaid, as prior to the pandemic, these entities were not reimbursed by the state for providing telehealth services. Second, the bill specifies that health care and mental health care services in Colorado can include speech therapy, physical therapy, occupational therapy, hospice care, home health care, and pediatric behavioral health care. If this bill were not passed, these specialties might not have known if they would be able to continue delivering their care over telehealth when the pandemic ended.
Well, we have discussed some national and state telehealth policy changes, but what about telehealth policy for private payers, like Aetna and Cigna? Well, currently, there are 43 states and Washington DC that have private payer telehealth payment parity laws, which is supposed to mean that in these states, which includes Colorado, insurers are required to reimburse telehealth at the same rate as for in-person care, and these laws also require parity for telehealth in coverage and services. While this sounds uncomplicated, I’ve read quite a few of these state parity laws and some of the language is so vague it gives private payers the discretion to create their own, possibly more restrictive telehealth policies. Private payer plans are also policy dependent, meaning that they may exclude telehealth for reimbursement under some policies. Essentially, telehealth policy for private payers depends on the payer, the state, and the specific health plan policy. Yup, complicated.
What does this all mean for the future of telehealth? Well, basically, we’ll see. It certainly seems that telehealth will continue to expand in use and popularity, even after the pandemic. A recent McKinsey survey found that 74% of telehealth users during the pandemic reported high satisfaction with the care they received, indicating that the demand for telehealth services is most likely here to stay. The national health legislative agencies and each state will need to examine their telehealth policies as the end of the PHE draws nearer, and they will have to determine which policies will remain and which ones should be altered or terminated.
Since telehealth requires that patients have access to technology and the internet, as well as some level of technological literacy, one of the factors that also needs to be addressed is the “digital divide,” which disproportionally disadvantages Black and Latinx individuals, elderly people, rural populations, and people with limited English proficiency. Many people in America still do not have access to a smartphone, computer, tablet, or broadband internet, and even the hundreds of millions of dollars that have been allocated to reduce these disparities may not be enough to overcome many of the systemic barriers in place that can impede such progress. For all Americans to equitably be able to access telehealth and benefit from all its services during and after the pandemic ends will require concentrated efforts at the state and federal level to determine the combination of administrative and legislative actions needed to do so. Now that doesn’t sound too complicated, does it?
Wishing you good telehealth!
Center for Connected Health Policy: https://www.cchpca.org