In a win for the millions of patients who took advantage of telehealth services authorized for coverage during the pandemic, Congress extended and expanded those services for another five months and will evaluate them for more permanent coverage.
In 2019, approximately 840,000 Medicare patients benefited from fee-for-service telehealth visits (visits made via video or audio-only calls). That number increased nearly 63-fold in 2020 as almost 52.7 million patients received such services under emergency authorizations included in the initial COVID relief efforts.
Recognizing the explosion in use of telehealth, a bipartisan group of 45 members of Congress drafted a letter to congressional leaders of both parties urging inclusion of an extension in the omnibus spending bill that will fund the government through September 30. The letter also recommended that Medicare coverage of telehealth be made permanent:
“We strongly support permanently expanding Medicare coverage of telehealth and removing other barriers to the use of telehealth because of its ability to expand access to care, reduce costs, and improve health outcomes.”
The omnibus spending bill, passed by the Senate on March 11 and signed by President Biden 4 days later, extends telehealth coverage for 151 days beyond the end of the pandemic-related public health emergency and significantly expands coverage. The public health emergency is currently scheduled to expire on April 16 but is subject to renewal by the US Department of Health and Human Services; it has already been renewed 8 times. The omnibus bill also includes a requirement that the Medicare Payment Advisory Commission conduct a study on the cost effectiveness of patient care under telehealth services. Congress will be able to use the study to consider making the changes permanent.
Extended and Expanded Care
Prior to the pandemic, telehealth coverage was mostly limited to routine visits under specific circumstances. For example, in rural communities, a patient would have to travel to a healthcare facility in order to receive “virtual” care from a doctor working in a separate, or remote, location. Patients in rural communities typically could not receive such services in their homes.
In March 2020, President Trump and Congress expanded telehealth coverage through executive actions and legislation, so that patients could receive services from their homes as well as any healthcare facility. The federal government relaxed certain standards governing privacy and security to encourage greater use of audio-only visits (i.e. connecting via standard telephones as opposed to video calls on the internet); more than 20 states changed their laws to permit audio-only visits. Mental health services were added to those eligible for reimbursement, and later legislation made from-home telehealth access for mental health services more permanent. However, the legislation also required a face-to-face visit in the 6 months prior to a telehealth visit for Medicare to provide reimbursement for mental health services, a requirement that was opposed by the American Telemedicine Association and others.
The just-passed omnibus bill includes the following changes to Medicare coverage of telehealth:
- Expands the range of reimbursable telehealth services to include audiology, occupational therapy, physical therapy, and speech pathology
- Delays the implementation of the 6-month in-person requirement for mental health services until 152 days after the public health emergency is formally ended
- Extends coverage and payment for audio-only services
- Extends the ability to use telehealth services to meet the face-to-face recertification requirement for hospice care
And, as noted, the legislation requires an evaluation of expanded telehealth services for consideration in making them permanent.
If we remain focused on the issue of access to care, then the question of making these changes permanent is less one of whether it should be done, but when. For many Americans, the convenience of telehealth can be the difference between seeking care and not obtaining it. The required study should address questions related to cost, effectiveness of care, and perhaps, how telehealth fits into the value-based care model that medicine has been trying to move towards. Such questions and their answers will advance the discussion, as will the expansion of broadband internet into rural communities that was funded by last year’s infrastructure bill. The latter makes the delivery of telehealth services even more feasible, and potentially more effective.
One critical question that needs to be addressed is whether telehealth increases government spending. Some evidence from the Kaiser Family Foundation indicates that Medicare payments for telehealth services during the pandemic have increased over the same services provided in-person, primarily because doctors who perform such services from non-healthcare facilities get paid at a higher rate. This raises two additional questions for consideration: Can this particular location-based payment system be modified to avoid this increase? And, if spending for telehealth services does go up, how will we pay for it?
It will be up to Congress to answer these questions, and to the voters to communicate their priorities to the people they elect.
Lok Wong Samson, Wafa Tarazi, Gina Turrini, Steven Sheingold, “Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristics and Location”, HHS Office of Health Policy, Dec 2021, https://aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf, accessed Mar 15, 2022
Press release, “President Trump Expands Telehealth Benefits for Medicare Beneficiaries During COVID-19 Outbreak”, CMS, Mar 17, 2020, https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak, accessed Mar 15, 2022
JoAnn Volk, Dania Palanker, Madeline O’Brien, Christina L. Goe, “States’ Actions to Expand Telemedicine Access During COVID-19 and Future Policy Considerations”, The Commonwealth Fund, Jun 23, 2021, https://www.commonwealthfund.org/publications/issue-briefs/2021/jun/states-actions-expand-telemedicine-access-covid-19, accessed Mar 16, 2022
US Dept. of Health and Human Services, “Consolidated Appropriations and American Rescue Plan Acts of 2021 telehealth updates”, Sep 8, 2021, https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/consolidated-appropriations-and-american-rescue-plan-acts-2021/, accessed Mar 20, 2022
American Telemedicine Association, Policy paper on in-person requirement, Jun 2021 https://www.americantelemed.org/wp-content/uploads/2021/06/ATA-Overview-of-In-Person-Requirements-1.pdf, accessed Mar 16, 2022
Ruth Reader, “There’s a big caveat in the telehealth expansion that Congress just passed”, Fast Company, Mar 12, 2022, https://www.fastcompany.com/90730800/theres-a-big-caveat-in-the-telehealth-expansion-that-congress-just-passed, accessed Mar 15, 2022
American Hospital Association, “Senate Passes Omnibus Spending Package with Health Provisions”, Mar 11, 2022, https://www.aha.org/2022-03-11-senate-passes-omnibus-spending-package-health-provisions, Mar 15, 2022
Alan Goforth, “Extension of telehealth included in $1.5 trillion omnibus spending bill”, BenefitsPro, Mar 14, 2022, https://www.benefitspro.com/2022/03/14/extension-of-telehealth-included-in-1-5-trillion-omnibus-spending-bill/?slreturn=20220215101750, accessed Mar 15, 2022
Wyatt Koma, Juliette Cubanski, Tricia Neuman, “Medicare and Telehealth: Coverage and Use During the COVID-19 Pandemic and Options for the Future”, Kaiser Family Foundation, May 19, 2021, https://www.kff.org/medicare/issue-brief/medicare-and-telehealth-coverage-and-use-during-the-covid-19-pandemic-and-options-for-the-future/, accessed Mar 16, 2022