- Congressional support for permanently expanding access to telehealth seems to be rising, though thorny questions persist around payment, timing and which flexibilities should be retained after the COVID-19 public health emergency expires.
- In a House subcommittee panel on telehealth Tuesday, lawmakers on both side of the aisle were supportive of the modality, especially nixing originating site and geographic requirements to coverage that made it difficult to use telemedicine widely, and allowing traditional Medicare to reimburse broadly for the service.
- "It's time to make Medicare reimbursement for telehealth permanent," Health Subcommittee Chairwoman Anna Eshoo, D-Calif., said.
The pandemic necessitated almost overnight adoption of telehealth, previously a niche delivery mode.
As COVID-19 cases started climbing, the Trump administration allowed traditional fee-for-service Medicare to reimburse for telehealth, along with relaxing privacy restrictions on what platforms could be used, allowing doctors nationwide to offer telemedicine to patients leery of in-office care. The changes, however popular, are temporary and will expire at the end of the public health emergency, currently slated to run out in April.
CMS added 144 telehealth services in 2020 temporarily covered by Medicare, and codified nine permanently in a December payment rule. However, the new additions only apply to patients in rural areas in a medical facility. Any more meaningful changes would require congressional approval.
Now, Congress is facing the tricky question of which flexibilities should remain once the brunt of the pandemic has passed.
Tuesday's committee mirrored similar Senate panels, in that a permanent expansion to a greater swath of the population enjoys bipartisan support, but legislators are split on what form exactly that expansion should take.
"As we all think about telemedicine, this is such a win-win. It's one of the best things since sliced bread — we should move on this as quickly as we can," Representative Fred Upton, R-Mich., said.
One of legislators' biggest concerns is that greater telehealth availability could actually inject more cost into the system through overuse. Witnesses noted the need for more data in this area, as telehealth has shown to cut costs in some studies and add costs in others.
Megan Mahoney, the chief of staff at Stanford Health Care and a witness at the hearing, said her system hasn't seen any evidence of greater costs.
"Fortunately, this has not been our experience. Telehealth is a tool in our toolkit that is largely substitute, not additive to in-person care," Mahoney said, noting roughly 30% to 40% of Stanford's visits are conducted virtually.
Many cost concerns legislators raised stem from problems endemic in the system itself. Telehealth built on a fee-for-service infrastructure "isn't a silver bullet for the deeper problems that exist," Eshoo said.
Politicians and witnesses were split on how much payers should reimburse for virtual care, making it unlikely parity — wherein federal payers reimburse for telehealth visits the same as in-person visits for the same service — will remain post-COVID-19. Additionally, lawmakers raised concerns about the potential for greater fraud if telehealth becomes more mainstream.
HHS' Office of the Inspector General said last week it was conducting significant oversight work to examine fraud and misuse, following reports telehealth fraud has been on the rise. However, Jack Resneck, a member of the American Medical Association's board, noted most such cases aren't actually criminals improperly billing Medicare for telehealth visits, but instead health fraud conducted via the phone.
"They're not actually using telehealth or any of these codes or broader coverage that we're talking about," Resneck said.
Members of the House subcommittee also seemed to agree audio-only telehealth should continue to be allowed post-pandemic, calling it a lifeline in rural or low-income communities with poor broadband access. However, it's insufficient to address many health needs, some noted.
Ateev Mehrotra, professor of health policy at Harvard Medical School, proposed a temporary period where the government allows audio-only calls while it works to expand broadband access, as a significant number of Medicare beneficiaries don't have access to video.
Broad support emerged for re-instituting stricter HIPAA restrictions, meaning post-emergency physicians would no longer be able to treat their patients over a broader array of platforms like Skype or Facetime.
"It's incredibly important that the HIPAA rules be reapplied again," Frederic Riccardi, president of the Medicare Rights Center, said.
Lawmakers have introduced a flurry of bills in recent years and during COVID-19 around telehealth, notably the CONNECT for Health Act, which would loosen the geographic and originating site restrictions. However, any near-term expansion is unlikely as the Hill focuses on coronavirus relief.