The COVID-19 pandemic will keep driving telehealth adoption, but use will likely ebb from its current unprecedented levels, experts and officials said this week during America's Health Insurance Plans' virtual annual conference.
"If I were trying to be controversial, of course I'd say, 'No, it's going to go away.' But of course no one believes that," said Karen DeSalvo, chief medical officer at Google Health and a health official during the Obama administration. "I think we'll land somewhere in between" pre-pandemic and current use, she said.
Before the COVID-19 crisis, telehealth was used mainly for behavioral and urgent care, with a focus in rural and underserved areas. But as patients looked for ways to receive healthcare without fear of contracting the coronavirus, use has snowballed.
Adoption has increased exponentially since March when the Trump administration temporarily rolled back myriad restrictions to telehealth access, including expanding fee-for-service Medicare coverage, waiving geographic restrictions and authorizing reimbursement for audio-only visits.
Many regulatory changes will only last the extent of the public health emergency. But experts say there's no going back now that hospitals and doctor's offices are investing in the tech, payers are reimbursing for it and consumers, including traditionally tech-wary seniors, have gotten a taste.
The number of fee-for-service Medicare beneficiaries using telehealth services alone expanded more than 11,718% between early March and mid-April, for example. Commercial payers are also reporting significant (albeit less dramatic) growth.
McKinsey estimates roughly 20% of all forecasted Medicare, Medicaid and commercial outpatient, office and home healthcare spending for 2020 could be digitized, though most analysts predict telehealth adoption will die down significantly in the back half of the year as the pandemic — hopefully — loses steam.
"I don't think it's going to be the wide-open field we've seen," Salesforce CMO Geeta Nayyar said.
A host of interconnected challenges still have potential to derail the future of virtual care, including which flexibilities will remain in place after the public emergency, uncoordinated state and federal regulations and whether major private payers will include telehealth in future plan designs.
Lawmakers and CMS have signaled they want to keep up the momentum. Though it's unlikely payment parity and relaxed HIPAA enforcement will endure, nixing geographic restrictions to care sites and allowing fee-for-service Medicare to cover a much broader swath of services could remain.
But the durability of the regulations remains a "big question mark right now," said Lisa Suennen, leader of law firm Manatt's digital and technology practice.
Additionally, the states and the federal government have different jurisdictions when it comes to telehealth, with Washington generally setting payment and the states and their medical boards impacting standards around care delivery.
States handle questions like what types of providers can practice telemedicine, whether physicians need an existing relationship with a patient prior to seeing them virtually and physician licensing requirements. The result has been a patchwork of regulations, frustrating telemedicine advocates, vendors looking to break into the space and doctors looking to practice across state lines.
"If one state opens their borders, another [state's doctors] could come in, but that state couldn't send their doctors out. Without that reciprocity, it's difficult to create continuous licensure across the states," Krista Drobac, executive director of the Alliance for Connected Care, said Tuesday.
Dozens of states are offering emergency licensing for qualified medical personnel during the pandemic, many with significant caveats. Experts worry a quick removal of the licenses when the pandemic is over could harm continuity of care for patients.
Groups like the Alliance for Connected Care are advocating for holistic multistate compacts with licensure reciprocity, or — a bigger reach — national licensing.
Almost 30 states participate in the Interstate Medical Licensing Compact, which allows doctors to apply for a license in another state through an expedited process. It's one of three compacts available for providers. The other two are for physical therapists and nurses, respectively, though in all compacts a significant number of medical professionals are left out.
Another important question is whether insurers weave telemedicine into their plans moving forward. Telemedicine advocates hope health plans will discount telehealth to nudge patients toward virtual-first care, and implement it for a wide variety of use cases like triage, urgent care, behavioral health, post-surgical consultations, chronic care management and more.
Major commercial payers, fresh off temporarily waiving patient some cost-sharing for COVID-19 testing and treatment and upping reimbursement for virtual care, seem open to the idea.
"It may drop back a bit after COVID moves by, but I think we're at a point now where we're going to maintain a much larger percentage of telehealth use," said David Platt, VP of large group sales at Blue Cross Blue Shield of Alabama.
But plan design can only go so far.
The novel coronavirus has ground the U.S. economy largely to a halt. Though all states are in some form of reopening to kickstart businesses, some 45 million Americans have filed for unemployment benefits during the pandemic. As people lose their jobs, they usually lose insurance, which (though there are some direct-to-consumer telehealth businesses) means they likely lose access to virtual care.
"Healthcare and health insurance don't scale to everybody. Digital health is a subset of that," Jane Sarasohn-Kahn, a health economist at HealthPopuli, said Tuesday. "We're in a real pickle here."
It's also important to ensure telehealth expansion applies to all Americans and doesn't aggravate existing disparities, such as access to broadband. More research also needs to be done on the quality of virtual care services, physicians and payers say.
But pickle or not, the pandemic has kicked off a once-in-a-lifetime shift in healthcare delivery, and experts say telehealth is here to stay.