Law passed during COVID special session expands telehealth coverage until April 2022.
During an August special session to address COVID-19, Tennessee legislators passed a law, HB 8002, requiring health insurers to cover virtual care the same way they would in-person care until April 2022.
Tennessee joined Alaska, Michigan, Utah, and several other states that passed telehealth legislation in the wake of the coronavirus pandemic.
Rural patients can face barriers to accessing in-person care under normal circumstances, let alone during a pandemic — telehealth can help fill the gaps. “Especially in rural Tennessee, you have people who now have access to healthcare who never had it before”, Dr. Justin Briggs told WSMV Nashville.
Coronavirus accelerates trend toward telehealth
As the coronavirus spread across the US in February 2020, the CDC recommended that “health care facilities and providers offer clinical services through virtual means.” Telehealth visits skyrocketed.
Blue Cross Blue Shield of Tennessee (BCBST) reported a dramatic increase in telehealth visits in its network: 18 times as many between March 16 and April 14 2020 as in the same period last year.
The spike led BCBST, which covers 70% of Tennesseans, to voluntarily expand telehealth coverage — first in March, as a stopgap measure, then permanently in May.
In Tennessee, there were reasons to support telehealth long before the pandemic. About 1 in 5 residents live in rural parts of the state, where medical specialists can be hard to come by. In recent years, telehealth initiatives have sprung up to fill the gaps. One program, STORC, brings virtual prenatal care to expectant mothers, helping address rural Tennessee’s high infant mortality rate.
But there are barriers to telemedicine adoption. One is technology. 18% of Tennessee households lack broadband internet access, making video visits difficult.
Additionally, healthcare regulations can keep providers from offering telehealth visits.
Regulatory Barriers to Telehealth Eased During the Public Health Emergency
Medicare coverage
“Under ordinary circumstances and with limited exceptions, Medicare telehealth services are limited to certain rural areas and can only be initiated in certain settings—not including the home, for most types of services”, explains Cal Marshall, healthcare law advisor at Chambliss Law. In the early days of the pandemic, the Centers for Medicare and Medicaid Services eased those restrictions.
Federal prescribing policy
“One of the significant remaining obstacles to telehealth practice in ordinary circumstances is the federal prohibition—to which there are very limited exceptions—on internet (including telehealth) prescribing of controlled substances when the prescribing practitioner has not conducted at least one in-person medical evaluation of the patient”, says Marshall. Because of the public health emergency, the Drug Enforcement Administration (DEA) eased restrictions on remote prescriptions of drugs like Adderall, Xanax, and Suboxone.
Telehealth parity
Private insurers don’t always cover patient costs or reimburse healthcare providers for telehealth equally to in-person visits. However, “many states, including Tennessee, have enacted various ‘telehealth parity’ measures designed to promote even-handed coverage (and sometimes payment for) telehealth by private insurers and in some cases also state Medicaid managed care plans”, says Marshall.
The new law
HB 8002 requires insurers to implement payment parity and reimbursement parity for telehealth services. In other words, patients must pay the same for a telehealth visit (payment parity) and healthcare providers must be paid the same (reimbursement parity) as they would for an in-person visit.
The new law builds on 2016 telehealth legislation that implemented payment parity in most situations, but not reimbursement parity. “Existing Tennessee law did not generally require that telehealth services be reimbursed in a manner consistent with the same in-person services”, says Marshall.
The new law also removes geographic requirements on original service location and expands the list of healthcare providers who are permitted to provide telehealth services — notably, to include drug addiction counselors.
The law passed with bipartisan support but was not without controversy.
State Rep. John Ray Clemmons (D) said he did not appreciate the way the law was handled. Clemmons suggested legislation could have been passed during the regular session in spring, and noted a still-valid executive order contained many of the same provisions as the telemedicine law. Still, Gov. Bill Lee called a special session to pass not only COVID-related legislation, but also a controversial anti-protest law.
Despite the disagreement, the State House passed the bill 91-0. The companion bill passed in the State Senate by 30-1.
State Law, National Trend
The Tennessee law echoes legislation passed across the nation in the wake of the coronavirus pandemic.
In March, the Centers for Medicare and Medicaid Services issued a waiver allowing reimbursement for video and telephone visits. Since then, 23 state legislatures passed bills aimed at removing barriers to telehealth adoption. In Congress, federal legislators have introduced dozens of bills with the same goal.
The increase in telehealth visits does not necessarily reflect an increase in healthcare access overall. G. Caleb Alexander, lead author of a telehealth study released in October, said “there has been a significant decline in primary care use, at least in the early phases of the pandemic.” He also noted “telemedicine is an imperfect substitute for many office-based consultations.” Blood pressure checks declined by half, putting patients at risk for undetected heart disease.
Not every part of the population is using telehealth equally, either. A November study found that Black and Brown patients, patients over 65, and patients who speak English as a second language are all less likely to opt for telehealth over in-person visits.
Still, many healthcare professionals and public health advocates hope Democratic and Republican legislators will extend telemedicine expansion laws past the pandemic. Despite partisan disagreements, “what [legislators] seem to be in agreement on is that telehealth is one of the ways that they want to make sure that Tennesseans have access to care”, said Dr. Briggs.
The Rural Health Information Hub shares data, case studies, and other resources about healthcare access in rural communities:
Telehealth in Rural Healthcare
Problem Addressed: Access to Healthcare
Written by Ciara McLaren
Published on November 17, 2020
Feature image: Ridofranz
Sources
Calvin Marshall, email interview with Ciara McLaren, Nov 11, 2020
“BlueCross Offering Telehealth Visits at No Cost”, Blue Cross Blue Shield of Tennessee News Center, Mar 12, 2020, https://bcbstnews.com/pressreleases/bluecross-offering-telehealth-visits-at-no-cost/, accessed Nov 11, 2020
“BlueCross Making In-Network Telehealth Services Permanent”, Blue Cross Blue Shield of Tennessee News Center, May 14, 2020, https://bcbstnews.com/pressreleases/bluecross-making-in-network-telehealth-services-permanent/, accessed Nov 11, 2020
Brittney L. Jackson, “Life after death of hospital”, Jackson Sun, Jan 19, 2018, https://www.jacksonsun.com/story/news/local/2018/01/19/life-after-death-hospital/1007168001/, accessed Nov 11, 2020
Bill Track 50, TN SB 2003, https://www.billtrack50.com/BillDetail/1240461, accessed Nov 11, 2020
“Percent of households with a broadband internet subscription”, State Health Compare, http://statehealthcompare.shadac.org/map/232/percent-of-households-with-a-broadband-internet-subscription-by-total#a/25/266, accessed Nov 11, 2020
Vardhmaan Jain, Mahmoud Al Rifai, Michelle T. Lee, Ankur Kalra, Laura A. Petersen, Elizabeth M. Vaughan, Nathan D. Wong, Christie M. Ballantyne, Salim S. Virani, “Racial and Geographic Disparities in Internet Use in the U.S. Among Patients With Hypertension or Diabetes: Implications for Telehealth in the Era of Coronavirus Disease 2019”, Diabetes Care, Oct 2020, https://patientengagementhit.com/news/telehealth-care-access-yields-a-health-disparities-amid-covid-19, accessed Nov 11, 2020
“Tennessee”, Rural Health Information Hub, https://www.ruralhealthinfo.org/states/tennessee, Nov 11, 2020
Manatt, Phelps, & Phillips, LLP, “Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19 – October 2020”, JD Supra, https://www.jdsupra.com/legalnews/executive-summary-tracking-telehealth-40474/
Lisa M. Koonin, Brooke Hoots, Clarisse A. Tsang, Zanie Leroy, Kevin Farris, B. Tilman Jolly, Peter Antall, Bridget McCabe, Cynthia B.R. Zelis, Ian Tong, Aaron M. Harris, “Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020”, Centers for Disease Control and Prevention, Oct 30, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm, accessed Nov 11, 2020
“Curtis, Welch Introduce Bipartisan Legislation to Assess Impact of COVID-19 Telehealth Policies”, Jul 21, 2020 https://curtis.house.gov/press-releases/curtis-welch-introduce-bipartisan-legislation-to-assess-impact-of-covid-19-telehealth-policies/#, accessed Nov 11, 2020
“Using telemedicine to improve rural women’s health and save babies’ lives”, Blue Cross Blue Shield News Room, May 22, 2018, https://www.bcbs.com/the-health-of-america/podcast/using-telemedicine-improve-rural-womens-health-and-save-babies-lives, accessed Nov 11, 2020
Carley Gordon, “Healthcare providers push for law changes”, Nashville News 4, Nov 10, 2020, https://www.wsmv.com/news/health/healthcare-providers-push-for-law-changes/article_5cc46e54-238e-11eb-a66e-cfbc698fde55.html, accessed Nov 11, 2020
“Study Highlights Shortcomings in Telemedicine Despite Large Increases in Remote Consults During COVID-19 Pandemic”, John Hopkins, Oct 2, 2020, https://www.jhsph.edu/news/news-releases/2020/study-highlights-shortcomings-in-telemedicine-despite-large-increases-in-remote-consults-during-covid-19-pandemic.html, accessed Nov 12, 2020
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