The last year saw a significant increase in the use of alternative health care delivery methods (especially telemedicine, or telehealth1), as patients either avoided or were unable to access in-person medical services due to the COVID-19 pandemic. The historic rate of utilization that telehealth reached during this period was accompanied by a significant shift in its public perception. From the results of one consumer survey, conducted in both March 2020 and March 2021, noted the following changes in respondent sentiment:
- In March 2020, 66% of participants were hesitant to utilize telehealth and doubted its quality.
- In March 2021, 88% of participants wanted to continue utilizing telehealth for non-urgent medical consultations.
- Pre-pandemic, 56% of participants thought it impossible to receive the same quality of care via telehealth.
- By March 2021, 80% of participants believed it possible to receive the same level of care through telehealth.
If these small survey pool findings are representative of the overall U.S. health care consumer community, then telehealth is here to stay—and it has the potential to increase access to quality medical care, especially in rural areas of the country where it is more difficult to access specialists and behavioral health services. In seeing the possibilities of telehealth for increased healthcare equity, both states and the federal government have responded by granting flexibilities and issuing regulations to support the widespread use of these services during the pandemic.
Below, Health Policy News has compiled a summary of key federal and state-level actions related to telehealth during the public health emergency (PHE), as well as what these changes could signify for use of telemedicine services after the pandemic.
Federal COVID-19 Telehealth Actions
In response to the COVID-19 pandemic, telehealth regulations were removed, and additional flexibilities granted, via federal waivers and federal policy such as the Coronavirus Preparedness and Response Supplemental Appropriations Act (“CARES Act”).
In early 2020, Department of Health and Human Services (HHS) Secretary Alex Azar waived telehealth requirements for originating site, device type, and patient and service eligibility. The CARES Act further expanded the authority of the HHS Secretary, allowing them to override any Social Security Act provision that would impede utilization of telehealth during the declared PHE.
The Act also contributed to the expansion of remote service delivery by granting telehealth coverage to Rural Health Centers and Federally Qualified Health Centers, eliminating barriers to access for patients with high-deductible health plans, and removing in-person requirements for patients receiving home dialysis and hospice services. Additional federal waiver actions taken during the pandemic include:
- The expansion of the 1335 Medicare waiver to pay for hospital, office, and other services via telehealth that were previously covered by Medicare on a limited basis
- Increased Health Insurance Portability and Accountability Act (HIPAA) flexibility, allowing HIPAA-covered providers to offer telehealth services using technologies that did not fully comply with HIPAA rules (such as FaceTime, Facebook Messenger, Zoom, and Skype)
- Reduction of cost-sharing for Medicare, Medicaid, and CHIP enrollees’ telehealth visits, in order to address affordability concerns
Federal funding was also key to telehealth expansion during the pandemic. The American Rescue Plan (“ARP”) funneled $500 million in federal funding towards rural healthcare with a focus on investment in telehealth infrastructure. The CARES Act also authorized $29 million per year for the next four years to telehealth network and telehealth resource center grant programs.
Additionally, recent action by the current administration demonstrates a commitment to making telehealth expansion a permanent priority:
- $14.2 million from the American Rescue Plan is being dedicated to expanding Pediatric Mental Health Care Access Act (PMHCA) projects into new states. These projects focus on integrating telehealth services into pediatric primary and mental health care.
- More recently (on June 15, 2021), the Telemental Health Care Access Act of 2021was introduced to the Senate. This bipartisan bill seeks to permanently expand access to tele-mental health services by repealing the statutory requirement that Medicare patients be seen in-person within six months of virtual mental health treatment. This legislation also calls for a report to be submitted to Congress on utilization of tele-mental health services one year after the conclusion of the PHE.
During the pandemic, all 50 states, as well as Washington DC and Puerto Rico, adopted temporary legislation to expand telehealth. Legislation varied by state, but all focused primarily on the following aspects of telehealth:
- licensure for out-of-state physicians,
- prior in-person contact requirement,
- originating site requirement,
- audio-only appointments, and
- reimbursement parity—for video calls, audio-only calls, and chat functions between patients and providers—for Medicaid and private insurers.
Most state legislation was time-limited, lasting for the duration of the PHE,which provides states with the opportunity to expand their telehealth flexibilities more permanently. Some states are already examining post-pandemic possibilities for these services: recent actions in Connecticut, Hawaii, Nevada, and Texas focus on payment parity for audio-only services, establishing the virtual patient-physician relationship, analyzing data related to telehealth, and providing telehealth services in educational centers.
Considerations for State-Level Actions
As states review legislation to ensure long-term accessibility to telehealth services, some areas for consideration include:
- Waiving the requirement for an in-person encounter between patient and physician before utilizing telehealth services, allowing relationships to be established entirely virtually.
- Prioritizing initiatives to raise awareness around telehealth availability, especially for rural populations. According to a Kaiser Family Foundation issue brief, 30% of rural Medicare beneficiaries report not knowing about telehealth offerings from their medical provider, versus 21% of urban Medicare beneficiaries.
To supplement federal actions in this area, states can play a central role in furthering health equity by taking legislative steps to permanently expand telehealth.
Increasing access to these services is key to providing access to quality medical care for many different groups—especially rural populations, low-income patients, and people of color.
Health Policy News will continue to follow and report on developments related to telehealth expansion at the federal and state levels.