The National Academy of State Health Policy (NASHP)’s annual conference looked a little different this year, due to being delivered in a virtual format, but still included the same informative content that conference-goers have come to expect.
As is typical, the conference sessions covered a broad range of topics; this year, largely related to the impact of the COVID-19 pandemic in areas including marketplaces and private insurance, Medicaid, health disparities, behavioral health, long-term care workforce, and state budgets. Other topics included the role of data in policy change, provider consolidations, cost control, and predictions of the impact of the election on health policy.
A theme that ran through several of the sessions was the huge uptick in telehealth usage during the pandemic. Data from the Commonwealth Fund shared in one breakout session underscored that increase: prior to the pandemic, telehealth was used for just over zero percent of primary care visits. In mid-April, that percentage peaked at about 14 percent. As of mid-June, it was slightly below eight percent. Speakers from several different states—including Kentucky, Maine, North Carolina and Virginia—as well as Washington D.C., across multiple panels, highlighted the power and successes of telehealth as well as the limitations of and remaining challenges related to its use.
The Promise of Telehealth
A common thread across speakers was the fact that, in driving the increased utilization of telehealth, the pandemic has shown us that this method of care delivery can work for more types of services than many originally expected. In addition to primary care visits, for example, telehealth can be successfully used for physical therapy and speech therapy—and several states noted it is particularly a good fit for behavioral health services (both individual and group counseling), case management, chronic disease care management, and post-discharge follow-up. In regard to behavioral health services, in particular, a study recently released by the Agency for Healthcare Research and Quality (AHRQ) found that telehealth medication-assisted treatment (MAT) programs for opioid addiction are at least as successful at retaining patients as those that deliver services in-person.
In the context of the pandemic, perhaps the most obvious benefit of delivering services via telehealth is that it allows patients and providers to avoid possible unnecessary exposures to COVID-19. Particularly during the pandemic’s early stages, this was a critical lifeline to continuity of care. Speakers w also highlighted additional promise it holds: expanding access for the homebound and those post hospital-discharge; expanding access in rural areas; addressing transportation barriers; and even eliminating barriers that can be caused by the need for childcare.
On the other hand, telehealth is not a good fit for all services—and brings its own challenges, of which states should be mindful.
First, unlike services noted above as well-suited to telehealth, speakers noted that services for disabled kids—and the delivery of treatment more generally—are often not well-suited to telehealth.
Also, while telehealth eliminates some access issues, it comes with its own. For example, individuals without access to high-speed broadband or data service face barriers to receiving services virtually. Lack of access to a high-speed Internet connection is more likely to impact people living in rural areas, but speakers noted that reliable access has also proven to be an issue in some inner-city areas, as well as for low-income populations. Additionally, some people may not have access to devices that can support traditional telehealth—that is, computers or phones with video capability. This issue can be addressed fairly easily by allowing for telehealth via audio-only lines. Another creative solution to these barriers includes leveraging community partnerships (for instance, with the Department of Education or schools providing computers to students, and with libraries providing internet access). Still other patients may not have access to a space for private conversations. Providers must also have access to HIPAA-compliant technology in general, though this is not currently required due to flexibility provided during the pandemic. Finally, more broadly, some speakers felt that telehealth works better in value-based purchasing payment models than fee-for-service models.
Telehealth also raises issues for states to consider related to the interstate delivery of care. For instance: Is care allowed if the patient or doctor live across state lines? Does the location of the doctor matter even if the doctor is licensed in the state in which care is being delivered? And, if the patient and provider are in different states, in which location is care considered to be delivered?
A less complicated question for providers to consider is how to deliver post-visit summaries and instructions in a timely manner. If this does not take place, they may see an uptick in calls from patients with questions.
Some speakers also raised concerns over whether telehealth usage could go too far and lead to overutilization—both of services generally, and specifically of services delivered via telehealth—and how states can protect against this possibility without limiting appropriate access.
Steps for States
All speakers agreed that for some time, telehealth has presented great opportunities for innovations in care delivery—and was given a beneficial boost by the pandemic. Providers who may have been nervous to wade into the new territory of telehealth pre-pandemic were forced to do so as a result of COVID-19 precautions and are now unlikely to turn back. However, it is important for states and providers to remain mindful of the challenges telehealth present: by both considering how to navigate them and what services are not appropriate for this method of care delivery.
Given the fallible nature of technology as well as varying levels of technological understanding across populations, for example, both patients and providers may require technical support. For patients, this would take the form of assistance with accessing telehealth apps; for providers, help with accessing multiple apps simultaneously—EMRs and interpreter apps, for example, and the telehealth app at the same time. Several states who presented about their approach to telehealth noted the importance of outreach efforts in getting both providers and patients to try telehealth and noted that all communications to patients must be done with language access standards in mind.
Most importantly, states should determine the types of visits for which telehealth is best suited—as well as ensure that both in-person and telehealth visits remain available (and that the choice between them is patient-driven). For services for which telehealth is well-suited, states should consider revisiting limitations on telehealth to make sure the limitations are appropriate and not creating barriers to services. As part of this effort, states may want to ensure that both reimbursement and cost sharing for telehealth and in-person services are equitable so that providers and patients are not improperly incentivized toward either model for financial reasons.
Overall, telehealth visits provide many benefits to both patients and providers. However, particularly as the COVID-19 pandemic continues to drive increased utilization of telehealth visits, states should be mindful of the challenges this model can present, and look to other states’ approaches as well as federal guidance in proactively determining how to address them.