What the House subcommittee hearing tells us about telehealth’s future

April 12, 2024 - Jeanette Ashlock was only 30, fresh off her honeymoon, when she first started experiencing multiple sclerosis (MS) symptoms.

“My muscles and body started locking up,” the National Multiple Sclerosis Society patient advocate told lawmakers. “I was losing my ability to control my movement and losing function.”

During a health subcommittee hearing on April 10, Ashlock described how her MS diagnosis in 2001 was the start of a harrowing journey, during which she experienced debilitating symptoms and was hospitalized numerous times. Though her MS has since stabilized, Ashlock still requires regular visits with her network of healthcare providers. Telehealth has become an essential tool for her to access this care.   

“I have used it for appointments with my primary care provider and some of my specialists, including my OB-GYN,” she said. “I have been able to talk to my providers for follow-up visits, for example, after having lab work done, and to talk through new health issues as they come up. Many times, I’ve called and been told that I can’t get an in-person visit for months, but I can get a quick telehealth visit right away.”

Ashlock’s remarks set the stage for the hearing conducted by the House Energy and Commerce Committee. The goal of the hearing was to discuss 15 legislative proposals currently in front of Congress that aim to support patient access to telehealth.

“It was impressive to see the levels of interest in this issue and that there generally appears to be bipartisan support for making permanent a number of the flexibilities granted during the PHE to make telehealth services more accessible,” said Amy Lerman, a member of the law firm Epstein Becker Green, in an email.

Telehealth use soared after restrictions on adoption and reimbursement were waived during the COVID-19 pandemic. However, once the public health emergency (PHE) was declared over last May, questions about telehealth's future rose. US lawmakers are now considering how to balance the ongoing need for telehealth-based care models and the potential pitfalls of expanded access to the care modality.

“As one witness commented during the hearing, changes in regulations will be most effective if they can meaningfully increase access to care, promote equity of care among populations, protect consumers, and deliver high-quality healthcare services,” said Lerman.

TELEHEALTH ACCESS IS A PRIORITY IN THE PANDEMIC’S WAKE

The subcommittee hearing made one thing clear: nobody wants to unnecessarily curb access to telehealth. From the US representatives to the witnesses, each emphasized the benefits of telehealth and expressed support for legislation that bolsters virtual care access.

“Telehealth is one of the few bright spots that emerged from the pandemic,” said Rep. Anna Eshoo (D-California) at the hearing. “During the public health emergency, HHS waived many outdated rules and payment policies surrounding telehealth coverage in traditional Medicare. And these changes really ensured the continuity of care for patients who needed to stay home and out of crowded care settings.”

Time and again, lawmakers asked Ashlock how limiting telehealth access would affect her, and her response remained the same. Without telehealth, the care services she needs would be stalled, leading to the progression of symptoms.

“I would not get the immediate care that I'm getting now,” she said. “I will have to wait for in-person appointments and with specialists that's like three months in advance. You have to wait to see my neurologist [but I] could be having a symptom going on where I need[ed] to see the neurologist like yesterday.”

Leaders from healthcare provider organizations highlighted the myriad ways telehealth helps them care for their patients.

Eve Cunningham, MD, group vice president and chief of virtual care and digital health at Providence, noted that telehealth has become an integrated part of the care delivery system, with telehealth services deployed across 93 acute care hospitals. Not only has telehealth boosted care quality, access, and patient satisfaction, but it has helped mitigate workforce burnout and hospital capacity challenges.

Telehealth creates scheduling flexibility and extends the specialty care workforce, enabling fewer physicians to meet the high demand for care, Cunningham said. She also highlighted Providence’s 92-hospital telestroke program, which helps the health system avoid thousands of costly transfers.

Still, telehealth use has dropped since the peak of the pandemic, and surveys and interviews show patient and provider preferences for in-person care, said Ateev Mehrotra, MD, professor of healthcare policy and medicine at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center, during the hearing. There are also legitimate concerns about the quality of care delivered through telehealth, reimbursement hurdles, and mitigating health inequities stemming from virtual care adoption.

ENSURING HIGH-QUALITY CARE AND PRESERVING CHOICE ARE KEY

New care delivery modalities are constantly emerging, making comprehensive clinical oversight critical, Mehrotra stated. Thus, amid the widespread adoption of telehealth in the last four years, the Centers for Medicare and Medicaid Services (CMS) and groups like the National Academy of Medicine must take the lead in ensuring parity between virtual and in-person care quality.  

Mehrotra said that to ensure care quality does not slip through the cracks, this monitoring must extend beyond health systems that provide telehealth to digital-only telehealth companies.

However, Mehrotra cautioned that it will not be possible to decide across the board when in-person care is more appropriate than virtual care and enshrine it in legislation. Even within a specialty or subspecialty, some components of care can be delivered virtually, and others cannot.

“We can identify and should identify and try to capture a category of visits where we really believe that service must be provided in person,” he told the representatives. “But I really urge you not to try to legislate broad categories of ICD 10 codes or subspecialty certifications.”

In addition to ensuring telehealth maintains care quality, new regulations must preserve patients’ choices regarding how they receive care. According to Fred Riccardi, president of the Medicare Rights Center, the option of in-person care is essential, especially for Medicare beneficiaries. In some cases, like long-term care and hospice, in-person care cannot replace virtual care.

“These are two high-risk, high-touch services where it's extremely important that in-person assessments continue to take place,” Ricardi said. “It's important to see a person in their environment, observe their activities of daily living, and I think, this is an area where we should really be cautious in waiving in-person assessments.”

Additionally, Ricardi stated that telehealth providers should not be used to meet network adequacy requirements. These requirements aim to ensure that health plans "maintain a network of appropriate providers that is sufficient to provide adequate access to covered services to meet the needs of the population served," according to CMS.

Ricardi noted that if health plans are allowed to incorporate telehealth providers to meet network adequacy, it could inadvertently corrode seniors' care access.  

PAYMENT PERMANENCY AND CROSS-STATE LICENSURE ARE CRITICAL BUT MUST BE CAREFULLY CALIBRATED 

Lawmakers spent considerable time probing telehealth reimbursement and licensure challenges, with varying advice from the assembled witnesses.

Lee Schwamm, MD, senior vice president and chief digital health officer at Yale New Haven Health System, noted how onerous telehealth licensure regulations are. Currently, telehealth can only be used across state lines if the provider is licensed in the state where the patient is located. Although states have created compacts to ease obtaining new licenses, it is still burdensome.  

“Even the [Interstate Medical Licensure] compact, which allows you to apply for a license in multiple states, does not [diminish] the administrative complexity of managing that license,” he said during the hearing.

Further, Mehrotra stated that the current regulations create a “chilling effect” on telehealth use as physicians are worried about risking their licenses while caring for their patients when they happen to be out of state.  

“[Patients] go on work trips, they have vacations, they go to school in other states and universities in other states, they work, they have conferences,” he said. “Health doesn't just exist in the state that you live in. Health exists wherever you go. And so, we need to be able to meet access to care where our patients are.”

Schwamm proposed one solution: change the definition of ‘site of care’ to the location of the provider rather than the patient.

“It makes no sense to anchor it to where the patient is located. The care is being rendered and prescribed where the provider is located…it would dramatically simplify all of these logistical hoops that we jumped through for what is effectively an arbitrary decision,” he added.

Licensure is not the only area where providers need more flexibility and certainty. The lack of clarity around telehealth reimbursement is also stifling adoption and investment.

According to Cunningham, without long-term, consistent telehealth payment policies, health systems cannot commit to investing in telehealth and other virtual care models like hospital-at-home and remote patient monitoring services.

“This model of care, it's a new standard of care, so we really need permanency in our ability to deliver this type of care,” she said.

Schwamm echoed this point, adding that hospitals can’t take necessary steps to restructure teams to support virtual care models without payment certainty. This could mean that despite growing shortages, parts of the workforce will remain idle when patients cannot come to the clinic for in-person care.

Amid debate on telehealth reimbursement models, Mehrotra noted that paying less for telehealth services may be better than telehealth payment parity, wherein payers reimburse for telehealth services at the same rate as the equivalent in-person services.

“Because we don't want to create distortions in the market where we're encouraging clinicians to give up their physical practice because they don't have to pay the rent, et cetera,” he said.

But Cunningham disagreed, pointing out that offering visits virtually does not mean that healthcare providers experience a significant change in costs related to overhead, implementation, workflow redesign, change management, licensing, credentialing, and billing.

Schwamm further cautioned that pricing telehealth services too low could discourage adoption.

“I think we have to recognize that we have to tie it to the true cost of providing the visit,” he said. “Right now, the cost is actually higher because we have to [have] full in-person capability and telehealth capability. If we have a permanent roadmap, we can start to actually readjust the expense base and figure out ways to deliver telehealth at lower costs. So, I would be in favor of a ramp that would take us from full parity down to a lesser value.”

NEW TELEHEALTH POLICIES MUST NOT EXACERBATE HEALTH INEQUITIES

Though telehealth shows significant promise in expanding access to healthcare and improving patient outcomes, the digital divide prevents many Americans from reaping its benefits.

The COVID-19 pandemic revealed the significant gaps in technology access and digital health literacy that leave certain populations behind. Schwamm emphasized the importance of efforts to close the digital divide but noted that payment permanency is required to make these efforts a reality.

Schwamm added that part of the solution is advancing access to broadband internet. Independent research conducted by BroadbandNow shows that at least 42 million Americans don’t have access to terrestrial broadband internet.

“I think strong government incentives to expand broadband availability, much like the Rural Electrification Act under Eisenhower, are a vital part of ensuring access to care,” he said. As I said before, healthcare is becoming increasingly digital. It's not just telemedicine; it's your healthcare portal access through the internet.”

Another strategy to close the digital divide is to expand access to audio-only telehealth. When asked whether audio-only telehealth could benefit communities facing broadband and technology access challenges, Cunningham said yes.

“Ideally, we always want to try to do a virtual visit or a video interaction with a patient, but when that is not available, the next best thing is to be able to provide an audio-based visit,” she noted. “And so, I think it's really important and critical that we include that in whatever legislation comes through.”

However, Mehrotra highlighted in his written testimony that there is limited data on the quality of audio-only telehealth visits. Additionally, clinicians are less likely to offer audio-only visits to underserved patients, which could lead to a system “where the poor receive phone calls, and the wealthy have video visits.”

Thus, Mehrotra called for mandates requiring clinicians who provide audio-only visits to attest that they also offer patients video visits. He further suggested limiting audio-only telehealth reimbursement to two to three years.  

As Congressmen ponder the benefits and pitfalls of making expanded access to telehealth permanent, it is becoming increasingly apparent that allowing pandemic-era flexibilities to expire at the end of the year would have devastating consequences.

“Without urgent action from Congress, millions of patients who rely on virtual care are less than 275 days away from a potential telehealth cliff,” said Telehealth Access for America Executive Chairmen Alye Mlinar in an emailed statement. “[The] hearing can be a positive first step for lawmakers to protect access to telehealth, without onerous restrictions, to ensure patients can access their doctor as easily as possible, and providers can unlock the full value of virtual care.”