[Senate Hearing 118-743]
[From the U.S. Government Publishing Office]
S. Hrg. 118-743
ENSURING MEDICARE BENEFICIARY ACCESS:
A PATH TO TELEHEALTH PERMANENCY
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH CARE
of the
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
NOVEMBER 14, 2023
__________
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
______
U.S. GOVERNMENT PUBLISHING OFFICE
62-174--PDF WASHINGTON : 2026
COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland TIM SCOTT, South Carolina
SHERROD BROWN, Ohio BILL CASSIDY, Louisiana
MICHAEL F. BENNET, Colorado JAMES LANKFORD, Oklahoma
ROBERT P. CASEY, Jr., Pennsylvania STEVE DAINES, Montana
MARK R. WARNER, Virginia TODD YOUNG, Indiana
SHELDON WHITEHOUSE, Rhode Island JOHN BARRASSO, Wyoming
MAGGIE HASSAN, New Hampshire RON JOHNSON, Wisconsin
CATHERINE CORTEZ MASTO, Nevada THOM TILLIS, North Carolina
ELIZABETH WARREN, Massachusetts MARSHA BLACKBURN, Tennessee
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
______
Subcommittee on Health Care
BENJAMIN L. CARDIN, Maryland, Chairman
RON WYDEN, Oregon STEVE DAINES, Montana
DEBBIE STABENOW, Michigan CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN THUNE, South Dakota
THOMAS R. CARPER, Delaware TIM SCOTT, South Carolina
ROBERT P. CASEY, Jr., Pennsylvania BILL CASSIDY, Louisiana
MARK R. WARNER, Virginia JAMES LANKFORD, Oklahoma
SHELDON WHITEHOUSE, Rhode Island TODD YOUNG, Indiana
MAGGIE HASSAN, New Hampshire JOHN BARRASSO, Wyoming
CATHERINE CORTEZ MASTO, Nevada RON JOHNSON, Wisconsin
ELIZABETH WARREN, Massachusetts MARSHA BLACKBURN, Tennessee
(II)
C O N T E N T S
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OPENING STATEMENTS
Page
Cardin, Hon. Benjamin L., a U.S. Senator from Maryland, chairman,
Subcommittee on Health Care, Committee on Finance.............. 1
Daines, Hon. Steve, a U.S. Senator from Montana.................. 3
Wyden, Hon. Ron, a U.S. Senator from Oregon...................... 4
WITNESSES
Perisho, Nicki, BSN, R.N., principal investigator and program
director, Northwest Regional Telehealth Resource Center,
Whitefish, MT.................................................. 6
Wallace, Eric, M.D., FASN, professor of medicine, UAB EMedicine;
medical director, co-director of home dialysis, and director of
the Rare Genetic Kidney Disease Clinic, Division of Nephrology,
Department of Medicine, University of Alabama, Birmingham, AL.. 8
Ellimoottil, Chad, M.D., MS, associate professor and medical
director of virtual care, University of Michigan, Ann Arbor, MI 10
Mehrotra, Ateev, M.D., MPH, professor of health care policy,
Department of Health Care Policy, Harvard Medical School,
Boston, MA..................................................... 12
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Cardin, Hon. Benjamin L.:
Opening statement............................................ 1
Daines, Hon. Steve:
Opening statement............................................ 3
Prepared statement........................................... 31
Ellimoottil, Chad, M.D., MS:
Testimony.................................................... 10
Prepared statement........................................... 32
Mehrotra, Ateev, M.D., MPH:
Testimony.................................................... 12
Prepared statement........................................... 36
Perisho, Nicki, BSN, R.N.:
Testimony.................................................... 6
Prepared statement........................................... 44
Wallace, Eric, M.D., FASN:
Testimony.................................................... 8
Prepared statement........................................... 48
Wyden, Hon. Ron:
Opening statement............................................ 4
Communications
AARP............................................................. 53
Alliance for Connected Care...................................... 55
Alzheimer's Association and Alzheimer's Impact Movement.......... 59
American Academy of Family Physicians............................ 61
American Council on Education et al.............................. 65
American Occupational Therapy Association........................ 67
American Physical Therapy Association............................ 71
American Society of Health-System Pharmacists.................... 73
American Urological Association.................................. 75
Association for Behavioral Health and Wellness................... 78
ATA Action....................................................... 80
Cadence.......................................................... 89
The Commonwealth Fund............................................ 100
Medical Group Management Association............................. 103
Mental Health Liaison Group Telehealth Work Group................ 105
National Association for Home Care & Hospice..................... 106
National Association of Rural Health Clinics..................... 107
National Health Council.......................................... 109
Partnership to Advance Virtual Care.............................. 111
Smith, Andrew.................................................... 114
Society of Thoracic Surgeons..................................... 114
UNC Health....................................................... 116
ENSURING MEDICARE BENEFICIARY ACCESS:
A PATH TO TELEHEALTH PERMANENCY
----------
TUESDAY, NOVEMBER 14, 2023
U.S. Senate,
Subcommittee on Health Care,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 2:30 p.m.,
in room SD-215, Dirksen Senate Office Building, Hon. Benjamin
L. Cardin (chairman of the subcommittee) presiding.
Present: Senators Wyden, Whitehouse, Hassan, Cortez Masto,
Daines, Thune, Young, Barrasso, Johnson, and Blackburn.
Also present: Democratic staff: Martha P. Cramer, Staff
Director for the Subcommittee on Health Care of the Senate
Committee on Finance, and Health Policy Advisor for Senator
Cardin; Michelle Galdamez, Legislative Aide for Senator Cardin;
and Matt Kearney, Legislative Correspondent for Senator Cardin.
Republican staff: Grace Bruno, Health Policy Advisor for
Senator Daines; and Matthew May, Legislative Aide for Senator
Daines.
OPENING STATEMENT OF HON. BENJAMIN L. CARDIN, A U.S. SENATOR
FROM MARYLAND, CHAIRMAN, SUBCOMMITTEE ON HEALTH CARE, COMMITTEE
ON FINANCE
Senator Cardin. The Subcommittee on Health Care of the
Senate Finance Committee will come to order.
The subcommittee today is holding a hearing on ``Ensuring
Medicare Beneficiary Access: A Path to Telehealth Permanency.''
I want to thank Senator Daines for his help in arranging for
this hearing. The two of us have worked together in regards to
the subcommittee's agenda during this year, and I want to
particularly thank Chairman Wyden and Ranking Member Crapo for
their support of our subcommittee and the work of our
subcommittee.
Mr. Chairman, thank you for giving us the ability to
establish an agenda. Our subcommittee has been busy during this
year. We have had an active agenda dealing with health
disparities, whether it is oral health or in rural communities
or home health-care challenges. We have worked to try to put a
spotlight on the disparities in our health-care system, and
solutions that can help improve access to health care.
I particularly also want to thank Martha Kramer of my staff
for work that she has done in putting together our agenda and
our hearings, including this hearing on telehealth.
Let me just, by way of background, give you a little bit of
my own personal experiences before the COVID pandemic, on the
need for telehealth. I think it was first brought to my
attention when I was visiting Pocomoke City, MD. For those who
do not know where Pocomoke City, MD is, Senator Daines, it is
in a very rural part of our State.
I was visiting a veteran's health facility and witnessing a
veteran getting ophthalmology care via telehealth through an
ophthalmologist located in Baltimore, 150 miles from that
clinic--and getting timely services. This individual would not
have had services but for telehealth, because it would not have
been possible to arrange the type of transportation to get to
Baltimore.
So I saw firsthand what telehealth means as far as access
to care--timely care and quality care. It is also less costly
for the consumer, that is for sure. The consumer can get the
care without having to change their work schedule and
transportation schedules, et cetera. It is what the patient
really wants, and it gives greater access to care than we would
otherwise see.
Now, COVID put a real spotlight on telehealth. We saw a 63-
fold increase in telehealth services in the Medicare population
during COVID. I think we understand why, and Congress responded
by removing some of the hurdles in telehealth.
Chairman Wyden, I particularly want to thank you and
Senator Crapo for allowing us to establish a task force to deal
with mental health issues. One of those task forces that dealt
with mental health dealt with telehealth. Senator Thune and I
cochaired that particular task force. So, many of our
recommendations were incorporated in changes in the law, and
that made it easier for telehealth services to be made
available during the COVID pandemic.
Now, some of those provisions were made permanent. Others
will expire. Several will expire at the end of 2024. We are
talking about issues such as removing the restrictions on
geography and who can receive telehealth services; the
requirement for an in-person visit for certain telehealth
services; the use of audio-only, which is an option that in
many parts of our country is the only option available; and the
qualifications for our qualified health centers and our rural
health centers to be able to qualify as service providers for
telehealth.
Those all will expire at the end of next year, and one of
the reasons we are holding this hearing is to underscore the
importance of permanency. Why? If you are investing in a health
facility, you need to have the predictability to know that
these services are going to be able to be continued well before
the expiration date. And if you are a patient with a provider
and you have a health plan, you need to know that health plan
is not going to be disrupted because Congress is a little late
in extending the programs. So, for all those reasons, it is
important that we deal with the permanency of these provisions.
That is the reason for this hearing.
There are a lot of misconceptions about telehealth that I
think have been dispelled by so many studies that have been
done. There have been studies done in regards to utilization
and cost. It has certainly been very much manageable, much less
than was anticipated when we acted in these areas.
So, there are a lot of areas where I hope we can dispel
some of the concerns that have been expressed over the years.
It is, I think, intuitive to us that if it is a choice between
receiving no care or receiving telehealth, that is not really a
cost to our system. That is access to care, keeping people
healthier, and doing what is necessary in order to make sure we
have quality health care available to all.
With that, I will turn it over to my ranking member--who
has been incredibly helpful in this year's agenda--Senator
Daines.
OPENING STATEMENT OF HON. STEVE DAINES,
A U.S. SENATOR FROM MONTANA
Senator Daines. Mr. Chairman, thanks, and I want to thank
you for your leadership with the subcommittee for this year.
You know, it has been productive. We have had some very good
hearings on relevant health policy issues. The chairman talked
about a few, and I look forward to continuing to work together
next year as well.
So I am glad we are turning our attention to the topic of
telehealth, as we have had some crucial decisions and have some
more coming at us to make when the Medicare pandemic-era
waivers expire next year. For our conversation today, we are
fortunate to be joined by a panel of some of the sharpest
telehealth minds our country has to offer.
So I want to thank you all for bringing your experience,
your expertise to our discussion, and for also making the trip
to DC. I understand you have all traveled a ways to be here. I
know that about Ms. Perisho, because she comes from my home
State in Montana, and Whitefish is a ways away.
By the way, for those of you not familiar with Montana's
geography, I appreciated the chairman's geography lesson today
on Maryland. Let me put one out here on Montana. Whitefish is
up in the very northwest corner of our State. It is the gateway
to Glacier National Park. It is where my Montana-Norwegian
ancestors actually built a hotel up there many, many years ago.
So I want to thank you, Ms. Perisho, for making the trip
and being here to discuss this very important topic. I know you
are a subject matter expert and passionate as well. We are glad
you are here.
As we all know, the COVID-19 pandemic drastically changed
our health-care sector in America, and our understanding of how
we deliver health care. Telehealth, which was underused and
understudied prior to 2020, suddenly became a crucial means of
delivering health-care services to patients. Through a series
of agency waivers and bipartisan legislation, the Medicare
program pivoted over the last few years to allow for greater
and more flexible telehealth access for beneficiaries.
Since implementing these flexibilities, we have seen the
advantages that telehealth offers, and the expanded access it
provides. In rural States like Montana and parts of Maryland,
telehealth has completely changed the game in terms of health-
care access.
At our rural health-care hearing earlier this year, I
highlighted that two of our most challenging barriers to
accessing care in rural States are distance and transportation.
We might add weather at times in our Montana winters. With the
ability to receive care virtually in the home, patients no
longer have to travel multiple hours to see their providers,
and the incorporation of audio-only telehealth has increased
access in areas without sufficient broadband infrastructure.
Telehealth also played a notable role in meeting the mental
health needs of patients, arguably the mental health crisis we
had during the pandemic, including in the Medicare population.
Even after the height of COVID, CMS data reports that the share
of Medicare services conducted via telehealth remains the
highest for mental and behavioral health specialists.
Sadly, we are all aware of the mental health crisis in our
country. Just last week in this committee, I joined my
colleagues in marking up the BETTER Act, which contains
significant proposals to expand access to mental health and
substance use disorder services in our Federal health-care
programs.
As the pandemic has demonstrated, telehealth can help us
bolster mental health services and address some of the access
gaps throughout the country. It is safe to say there is no
going back now, as we have seen how transformative telehealth
can be. We have proved the concept. The question is, how is
Congress going to shape the future of telehealth when the
Medicare waivers expire at the end of next year?
Policy decisions such as originating site eligibility,
appropriate reimbursement, and in-person requirements will need
to be addressed, and we are here to begin considering some of
these policy questions. My colleagues in this committee and I
have demonstrated our commitment to telehealth through various
pieces of legislation which support and expand the
flexibilities Medicare beneficiaries have relied on now the
last few years.
My hope is that in today's conversation, we can help
further inform the committee as we deliberate telehealth
permanency.
Thanks again to our witnesses. We appreciate your continued
work, your dedication, your expertise. We look forward to
hearing from you. And most of all, thanks, Mr. Chairman.
[The prepared statement of Senator Daines appears in the
appendix.]
Senator Cardin. Thank you. Thank you, Senator Daines.
Now I will recognize the distinguished chairman of our
committee, Senator Wyden.
OPENING STATEMENT OF HON. RON WYDEN,
A U.S. SENATOR FROM OREGON
Senator Wyden. Thank you, Mr. Chairman. I want to thank you
and Senator Daines. And I am going to be very brief and just
make sure people understand that what Senator Cardin and
Senator Daines are doing is so important.
If you look at the history of this committee, we have been
intensively involved in Medicare, really looking at its origins
and how it has evolved over the years. And one of the things I
am proudest of is, we have helped shape the future of Medicare,
particularly by using telemedicine.
And we did that, colleagues, starting--you cannot give
enough credit to the late Orrin Hatch, our chairman--with our
CHRONIC Care bill, because our CHRONIC Care bill was the first
piece of legislation to say, look, Medicare is not just acute
care, like you broke your ankle, for example, Part A of
Medicare. Or if you had a horrible case of the flu and then you
went to the doctor, that was Part B.
By the time Chairman Hatch and I and many of our colleagues
here got together, millions of seniors did not really use
Medicare that way. They had two or more chronic conditions:
cancer, diabetes, strokes, COPD. They needed a very different
kind of health system. We pulled that together in the CHRONIC
Care Act of 2018.
And at the center of the CHRONIC Care Act were our
telemedicine provisions, and on a bipartisan basis, we did some
awfully good work. I mean, we made it possible to expand access
to innovative telehealth treatment options for life-altering
conditions--for example, like telestroke and remote monitoring
of diabetes.
That was CHRONIC Care 1.0, folks. And one of my proudest
moments, I will tell my Republican colleagues, is I remember
getting a call from Seema Verma, who was then the head of the
Centers for Medicare and Medicaid Services, and she said, ``We
just love what you guys are doing in chronic care. I hope we
can work together on it.'' And she pretty much used the
telemedicine provisions that my two colleagues are talking
about, that were in the CHRONIC Care Act, as the foundation for
dealing with COVID, where we had so many folks at home.
So now we have a chance to build on that, and that is what
is so exciting about what my colleagues are doing. I am not
going to be able to stay, but I am going to give the panel a
couple of questions first. I would really like to see us expand
State/interstate licensure compacts, because if we look at what
we did with CHRONIC Care 1.0, it was all about information
technology and common sense, just common sense to expand these
compacts in the digital age when people are so mobile.
And second, I am going to pose a question, particularly to
you, Ms. Perisho, about the next innovative ideas for
telehealth. Give us the next ideas, if you would, to pick up on
telestroke and remote monitoring of diabetes, and help us fill
these rungs with people who are going to be talking to Senators
of both political parties about some of the exciting new
technologies we can do when Senator Cardin and Senator Daines
and all my colleagues here take us to CHRONIC Care 2.0. Because
that is what I am committed to doing.
Thank you both, and I will look forward to following up
with both of you.
Senator Cardin. Well, thank you, Chairman Wyden. We
appreciate your support and what you have done to advance
access and quality to health care. So, thank you very much for
your leadership.
I will now introduce our four witnesses, and I want to join
with Senator Daines in thanking each of you for being here. We
do have an expert panel that can really help us understand the
current state of play of telehealth, but just as importantly,
where the hurdles are for the expansion of this care--and where
are we heading, and how can we make sure that our health
policies allow for the most advanced forms of health care to be
available to our constituents.
So I thank all four of you for being here. Your entire
statements will be made part of our record. We will ask, after
the introductions, that you proceed, in about 5 minutes, to
summarize your comments, so that we have time for questions
from members of the committee.
First--and the order I introduce you is the order that you
will make your presentations. First, Nicki Perisho--who has
already been mentioned by two colleagues--is the program
director of the Northwest Regional Telehealth Resource Center
based out of the University of Utah.
Ms. Perisho joined her team virtually from Whitefish, MT,
and I now know where that is; thank you very much. She has
worked in telehealth since 2010 and is considered a pioneer in
the field, leading efforts toward telehealth growth,
utilization, and sustainability for more than decade.
Dr. Eric Wallace is a professor of medicine in the Division
of Nephrology at the University of Alabama at Birmingham. In
2015, he began using telehealth for the care of his patients on
home dialysis, and for patients with the rare disease called
Fabry disease.
In 2018, he was hired as the medical director of the UAB
Health Systems Telehealth Program. In this role, he oversaw the
rapid transition of health-care delivery to telehealth during
the COVID-19 pandemic.
Dr. Chad Ellimoottil is the medical director of virtual
care for the University of Michigan Medical Group, an associate
professor of urology at the University of Michigan, and a
telehealth policy researcher. In his role as medical director
of virtual care, he leads the strategic planning and
implementation of virtual-care services across all specialties,
overseeing approximately 450,000 virtual encounters annually.
And then, Ateev Mehrotra is a professor in the Department
of Health Care Policy at Harvard Medical School. His research
focuses on delivery and innovation and their impacts on access,
quality, and spending. These include innovations such as
telemedicine, retail clinics, and e-visits.
He also is interested in the role of consumerism and
whether price transparency and public reporting of quality can
impact patient decision-making.
With that, we will start with Ms. Perisho.
STATEMENT OF NICKI PERISHO, BSN, R.N., PRINCIPAL INVESTIGATOR
AND PROGRAM DIRECTOR, NORTHWEST REGIONAL TELEHEALTH RESOURCE
CENTER, WHITEFISH, MT
Ms. Perisho. Chairman Cardin, Ranking Member Daines, and
members of the Senate Committee on Finance and Subcommittee on
Health Care, I want to take time to thank you for this
opportunity. I would also like to note that the views I am
sharing are my own personal opinions and do not reflect on the
Health Resource Services Administration, nor my employer the
University of Utah, or the NRTRC.
I am really pleased that the subcommittee is exploring
telehealth and what it means to potentially make it permanent
or extend the waivers past 2024. I am very passionate about the
right care, the right time, the right place for patients, and
ways that work for them, while at the same time providing
appropriate payment to the providers, practitioners, and
facilities providing those health-care services.
I am humbled to be with my panel today, but what is missing
from the panel, in my opinion, is patient perspectives. So I
will do my best to put the patient perspective into my
testimony.
So first of all, I am a nurse. I grew up in a household
with health-care professionals, and I am very passionate and
believe it is your right to have access and to receive high-
quality health care, regardless of the geographic location you
reside in.
Thank you, Senator Daines, for leading in with a little
background about Montana. That is where I live, and so finding
high-quality health care is not always easy. It is not always
safe; it is not always affordable. Montana is the fourth
largest State by area. It is the eighth least populous State,
and the third least densely populated State.
Our largest city within our borders is Billings, coming in
with a population of about 118,000. I think that is about the
number of protestors who are out in the Mall right now. So that
is our biggest city in our State, and that city of Billings is
about 450 miles from my hometown of Whitefish.
I have been involved in telehealth since 2010, and some
people joke with me that that was before telehealth was cool,
and I have to agree. I think one of my most memorable--what got
me into telehealth and to be passionate and drive the wagon is,
in 2010, we started a telestroke program.
We had funding through the USDA, the U.S. Department of
Agriculture, and the Distance Learning and Telemedicine
funding, to provide audio, video, and telehealth equipment to
three Critical Access Hospitals in rural Montana. We had a team
of neurologists that we worked with that were very passionate
about telehealth as well, and I saw firsthand the benefits of
stroke patients being administered tPA--which is the clot-
busting drug for an ischemic stroke--for patients who otherwise
would not have received this medication.
To this day, it has grown to 13 Critical Access Hospitals,
and this summer they actually administered their hundredth dose
of tPA. All of these Critical Access Hospitals had never given
tPA before. So not only is that a cost saver for the health
system, because a lot of these patients would have long-term
modalities that would need therapies, but now a lot of them are
able to live their lives as they were.
So, based on my experiences in working with telehealth,
there are four key areas that I would like to see made
permanent: eliminating the geographical requirements for
origination sites; expanding to locations outside of the home;
preserving audio-only telehealth visits; and expanding provider
types for telehealth services, while ensuring payment parity.
It would be a disservice to limit the originating site to a
patient's home or a clinical location. Public libraries,
community centers, and fire stations, even a patient's parked
vehicle--somewhere where they can access the Internet--have
provided disadvantaged populations and practitioners access to
telehealth. We call these telehealth access points, and we are
mapping them throughout the Nation.
Audio-only telehealth is important to increase accessed
care to Medicare beneficiaries, because it does not require
them to be proficient using a smart device, having a webcam, or
even having an Internet connection. Broadband is not yet
available to everyone, and it can be expensive in rural areas.
If audio-only telehealth is not made possible, it is possible
that some individuals might not be able to access health-care
services. Expanding provider types--Federally Qualified Health
Centers and RHCs--they provide primary care, behavioral health
services, dental, and pharmacy services to underserved
communities. It worked during COVID.
I also think that physical therapists, occupational
therapists, and speech therapists should have permanent
availability to see patients virtually--and payment parity.
Practitioners are expected to bill for certain things, and if
that service meets the definition of the code that they are
billing for, they should be reimbursed at the same amount,
regardless of whether or not the visit was in-person or via
telehealth.
So, in closing, I really believe that telehealth plays a
critical role in improving access to timely and regular health
services with highly qualified practitioners, especially for
patients with challenges that affect access and care
coordination. So, thank you for your attention on this critical
matter.
[The prepared statement of Ms. Perisho appears in the
appendix.]
Senator Cardin. Thank you for your testimony.
Dr. Wallace?
STATEMENT OF ERIC WALLACE, M.D., FASN, PROFESSOR OF MEDICINE,
UAB EMEDICINE; MEDICAL DIRECTOR, CO-DIRECTOR OF HOME DIALYSIS,
AND DIRECTOR OF THE RARE GENETIC KIDNEY DISEASE CLINIC,
DIVISION OF NEPHROLOGY, DEPARTMENT OF MEDICINE,
UNIVERSITY OF ALABAMA, BIRMINGHAM, AL
Dr. Wallace. Chairman Cardin, Ranking Member Daines, and
distinguished members of the Senate Finance Committee, thank
you for the opportunity to testify on behalf of the University
of Alabama at Birmingham, the American Medical Group
Association, and the American Society of Nephrology.
I am the medical director of Telehealth for the University
of Alabama at Birmingham. My role in telehealth started in
2013, when I recognized that my patients on home dialysis and
with rare disease were spending hours driving to see me. I
realized that their lives might be made better if we could
deliver the same quality of care remotely. During the initial
days of the COVID-19 pandemic, telehealth saved lives and
provided a case study of just how important telehealth is in
delivery of care.
In addition to the rapid transition to telehealth clinic
visits, telehealth was critical to rural inpatient care. When
patients with COVID-19 got stuck in hospitals unable to care
for them and nowhere to transfer, telehealth enabled UAB to
care for people who otherwise would have been left to die.
Multiple times I was able to facilitate the transfer of a
critically ill patient from one rural hospital without
telehealth to another rural hospital with telecritical care and
telenephrology. Telehealth provided the resources needed to
care for them in a way that was never before possible. The
COVID-19 pandemic demonstrates that telehealth has the
potential to transform a rural hospital bed from available but
unusable to available and useful.
Congress played an important role in allowing for this
complete and successful pivot to telehealth during the early
days of the pandemic by providing targeted regulatory
flexibility, but these flexibilities have not been made
permanent. We have been to war with disease armed with
telehealth, only to find we are battling new barriers and
regulations, and nothing was permanent. Providers and clinics
found it easier to give up on telehealth than to face an
impossible onslaught of changing regulations, and as such, the
utilization of telehealth decreased.
As we look to the future, how will telehealth play a major
role in the success of any health-care system? Number one,
telehealth is vital to the survival of rural health care by
providing access to subspecialty support. Number two,
telehealth is and will continue to play a large role in value-
based care by reducing no-show rates and readmissions, and
shifting more chronic disease management to the home. And
three, alleviating nursing and provider staffing shortages by
leveraging urban and national workforces.
It is important to note that telehealth means more to
people than just health care. Since inception, UAB Telehealth
has saved 28.5 million miles of driving for patients. This is
the greenhouse emissions equivalent of having 2,600 passenger
vehicles off the road for an entire year. Furthermore,
Alabamians gained $16 million in work productivity by using
telehealth.
Just as there was a need for telehealth before COVID-19,
there is a need for telehealth now, and there will be a need
for telehealth in the future. To allow this new area of
medicine to continue to benefit patients, particularly those
living in rural or urban areas with limited access to
traditional sites of care, Congress must enact five policies.
Number one, the geographic restriction on telehealth should
be permanently eliminated. Telehealth is for the urban and
rural. Prior to COVID-19, patients had to do their telehealth
in rural areas. I will never forget a patient of mine who was
disabled. The patient lived no more than 2 miles from our
clinic. But getting in and out of a vehicle and parking close
to our clinic was enough to make any clinic visit a half-day
event. He found an article that I was doing on telehealth, and
he showed me that article, and he said, ``Is this for me?'' And
I said ``no,'' because he lived in an urban area. Access to
care problems are not geographically restricted; why should our
regulations be?
Number two, the originating site requirement should be
eliminated. Delivery of telehealth care within brick-and-mortar
sites is a great way to care for patients who do not have
access to technology. However, the home also has significant
advantages in its ability to be scalable and reduce the need
for health-care infrastructure.
Three, telehealth should be covered at parity with in-
person visits. Telehealth visits continue to require staff,
videoconferencing platforms, and provider time. Telehealth does
not equate to a fast visit.
Four, audio-only visits should continue to be covered. Some
patients just cannot access video. Those are the same patients
who need us the most. If audio-only goes away, these patients
will be forced to choose between an in-person visit or nothing
at all, and I fear they are going to choose the latter.
Five, prescribing of controlled substances that are not
Schedule II, specifically suboxone and antiseizure medicines,
should be allowed over telehealth.
In closing, permanent coverage of telehealth is critical to
the survival of rural health, the future of our health-care
system's ability to deliver equitable care regardless of
geography, and is integral to our ability to deliver on the
promise of value-based care.
Thank you for your time, and I look forward to your
questions.
[The prepared statement of Dr. Wallace appears in the
appendix.]
Senator Cardin. Well, thank you for your testimony.
Dr. Ellimoottil?
STATEMENT OF CHAD ELLIMOOTTIL, M.D., MS, ASSOCIATE PROFESSOR
AND MEDICAL DIRECTOR OF VIRTUAL CARE, UNIVERSITY OF MICHIGAN,
ANN ARBOR, MI
Dr. Ellimoottil. Thank you. I would like to begin by
expressing my gratitude to the members of the subcommittee for
this opportunity to discuss the current and future state of
telehealth in the United States.
Telehealth took off during the early stages of the
pandemic, thanks to essential flexibilities such as removal of
the geographic restrictions and coverage for audio-only
telehealth. In a MedPAC survey, 90 percent of Medicare
beneficiaries reported satisfaction with their telehealth
visits.
Currently, telehealth accounts for about 10 percent of
Medicare's office visits, a rate that has been stable since
July 2021, and is anticipated to remain so until December 21,
2024. However, I am concerned about the potential decline in
telehealth usage after that date, which could either occur
rapidly or gradually.
Preventing both the fast and slow death of telehealth
depends on the actions of Congress and CMS. The fast death of
telehealth could occur if the originating site and geographic
restrictions were reinstated. If that were to occur, there is
no doubt that we would revert to the pre-pandemic levels of
telehealth, where fewer than 1 percent of health-care providers
and patients were utilizing telehealth services. The slow death
of telehealth may occur when patients and providers become
increasingly frustrated by regulations and unexpected bills,
and ultimately stop using telehealth. Four key factors could
contribute to this slow decline, if left unaddressed.
Factor number one is the lack of coverage alignment among
payers. Medicare sets the standard, and many commercial payers
follow. If Medicare continues to view expanded telehealth
coverage as temporary, commercial payers will reduce or
eliminate their coverage for telehealth services. This is
already underway, and we are witnessing the development of a
fragmented telehealth payment system that creates confusion for
both patients and providers. Imagine being a patient and not
knowing whether your insurance will cover a video visit, a
phone call, or neither. The path of least resistance for both
patients and providers would be to schedule the next follow-up
as an in-person visit, even if a video visit was clinically
appropriate.
Number two is the loss of audio-only coverage. My personal
research, along with that of others, has shown that there is an
obvious digital divide. Recently, I experienced this myself in
clinic when I attempted to conduct a video visit with a patient
from rural Michigan who was experiencing connectivity issues.
After about 5 minutes of troubleshooting, I resorted to picking
up the phone and conveyed the exact same information about
surgical options for his enlarged prostate over the phone. Such
scenarios are quite common, particularly for Medicare
beneficiaries residing in rural and underserved communities.
If audio-only visits become ineligible for billing in the
future, health-care providers will simply not offer them, and
as a result, Medicare beneficiaries will lose this option for
remote care.
Factor number three is the loss of payment parity. The
prevailing narrative suggests that the practice expenses
related to telehealth visits are lower than those for in-person
visits, thereby supporting the argument for payers to reduce
reimbursement rates for telehealth visits.
While on the surface this narrative is quite convincing,
the reality is that, unless your practice is entirely virtual,
it is unlikely that your practice expenses have decreased. In a
practice where 1 out of 10 office visits is virtual, health-
care providers still incur the same costs for maintaining the
physical office, equipment, and salaries of staff like clerks
and nurses who schedule visits, collect records, and provide
all of the care between visits. Practically speaking, these
expenses do not decrease by 10 percent just because 10 percent
of your visits are now virtual.
Number four is the implementation of guard rails that lack
clinical evidence. While we all recognize the importance of
preventing fraud and abuse, implementing guard rails like
mandating periodic in-person visits for patients receiving
telehealth services only creates barriers for health-care
access.
In 2022, the Office of Inspector General evaluated 742,000
telehealth providers and found that only 0.2 percent displayed
potentially fraudulent or abusive patterns. There is no need to
impose in-person guard rails on the 99.8 percent of health-care
providers who use telehealth without exhibiting any patterns of
fraud and abuse.
Actions of Congress and CMS in these four key areas can
help prevent the slow death of telehealth after December 31,
2024. I understand that there is appropriate concern, both
within this committee and beyond, that permanent expansion of
telehealth will result in excess health-care utilization and
spending. Based on my research and my experience overseeing
telehealth at the University of Michigan, I can confidently say
that this is unlikely to happen. In my written testimony, you
will find data that sheds light on what researchers have
learned over the last 3 years.
While no single study or report can definitively capture
the entire impact of telehealth on cost, quality, and access, I
believe that most researchers will at least agree on these
three points.
Point number one: telehealth expansion has not led to
runaway health spending or utilization. Point number two is
that telehealth does not compromise quality of care for
patients. And point number three is that telehealth improves
access to care.
In the end, making telehealth expansion permanent is about
ensuring that Medicare beneficiaries have choices in their
care. Whether it is in-person, via video, or through a phone
call, I applaud this committee for its extensive efforts in
making telehealth coverage permanent.
[The prepared statement of Dr. Ellimoottil appears in the
appendix.]
Senator Cardin. Thank you very much for your testimony.
Dr. Mehrotra?
STATEMENT OF ATEEV MEHROTRA, M.D., MPH, PROFESSOR OF HEALTH
CARE POLICY, DEPARTMENT OF HEALTH CARE POLICY, HARVARD MEDICAL
SCHOOL, BOSTON, MA
Dr. Mehrotra. Thank you, Chairman Cardin, Ranking Member
Daines, and other distinguished members of the subcommittee. I
am honored to testify before you on a topic of such importance
to Americans and their health.
I conduct research on telehealth because I hope we can
address the common complaint that I hear from my patients, and
what I am sure you hear from your constituents: that so many
Americans have difficulty accessing care in a timely manner. In
my testimony today, I wanted to touch upon how I think recent
research can inform permanent telehealth policy.
At the start of the pandemic, some contemplated whether the
unprecedented growth in telehealth was the beginning of a new
normal. The reality has been more of a modest change. The
number of telehealth visits in the Medicare program has fallen
substantially, and now constitutes roughly 5 to 10 percent of
visits. In surveys and interviews, both patients and physicians
have greatly valued the availability of telehealth and want it
to remaim an option, but they also remain uncertain about the
quality of care provided.
Evidence is beginning to emerge on the impact of greater
use of telehealth during the pandemic. In my own research,
greater use of telehealth results in increased visits, roughly
2 percent more visits per person per year. The relative
increase in visits was larger among lower-income, non-White
patients, and was associated with small improvements in chronic
disease medication adherence and fewer ED visits.
However, these changes were accompanied by a $248 or 1.6-
percent increase in health-care spending per person per year.
Our results are generally consistent with other recent work.
Based on these findings, I recommend that Congress permanently
eliminate geographic and site origination requirements, and
allow video visits for all conditions.
While telehealth does not reduce health-care spending, the
increase in spending is modest and there are some improvements
in access and quality. Perhaps most importantly, patients and
clinicians want telehealth to remain an option, and given the
research, it is going to be hard to justify stopping coverage.
Also, almost 4 years after the start of the pandemic, it is
important to signal to clinicians that telehealth payments are
here to stay, so that they can make the investments in
telehealth with more certainty.
I recommend that telehealth visits be paid less than in-
person visits. Payments for office visits are based on the time
a clinician takes to provide care and the practice expense
necessary to provide that visit. While they do require some
overhead, telehealth visits do not require the same practice
expenses, and physicians agree that these visits are less
costly. Paying the same amount for telehealth visits will
create distortions in the market. It will give
virtual-only telehealth companies a competitive advantage. It
will also incentivize clinicians to give up their practices.
Roughly 5 percent of mental health specialists have given up
their physical office and gone virtual-only. I think this is a
problem, because patients want the option to see clinicians in
person.
I want to end on a different issue that was raised by
Senator Wyden, which is related to physician licensure. The
pandemic prompted a temporary relaxation of State licensure
requirements, and during the early parts of the pandemic, many
Medicare beneficiaries continued to seek care from their out-
of-State physicians.
Out-of-State telehealth use was greatest for some specific
conditions such as cancer, among patients who live in areas
right near a State border, and in more rural States such as
Montana and South Dakota. Most of these temporary regulations
have now expired, and patients are rightfully frustrated.
Patients wonder why they must take a telehealth visit in their
car, in a parking lot just across the State border, just to
follow the rules.
This problem can be addressed in a straightforward way.
Building off precedent in the Sports Medicine Licensure Clarity
Act and the VA MISSION Act, the Congress can create a narrow
exception. Under this exception, patients can get follow-up
care from a physician in another State via telehealth if they
have an established prior relationship with that physician.
This is not a controversial idea. Key groups such as the
American Medical Association and the Federation of State
Medical Boards have supported the need for this type of narrow
exception.
Again, I thank you for allowing me to appear before you
today, and I look forward to your questions.
[The prepared statement of Dr. Mehrotra appears in the
appendix.]
Senator Cardin. Well, once again, let me thank all four of
you for your testimonies and for your being here, and for the
work you have done in this field.
I want to sort of harp on two points here first of all:
one, the need for permanency of the provisions that are
currently in law; and second, as just was pointed out, what
additional improvements could we make that would make it easier
for patients to access telehealth, or for providers to be able
to provide telehealth?
I think you have made a very strong point in regards to
convenience. I think you made a very strong point in regards to
costs. Dr. Wallace, particularly, I think your point about the
carbon footprint is a cost to carbon. So that is a cost issue.
And loss of productivity, I think we all could understand. You
have to take a day off from work in order to see a doctor,
particularly if you are in a rural community and you have to
travel a long distance. I think we can all visualize how that
additional cost is imbedded in a savings to telehealth.
And then last, if it is a choice between getting telehealth
or no health care, no services at all, ultimately it is going
to lead to a more difficult and costly intervention in health
care. Unfortunately, our scorekeepers do not give us any credit
for any one of those three. So that is where the struggle comes
in.
The good news is that the cost issues have been manageable
that we have gotten. So the dire projections have not come
true. It has been certainly within the budgets that we have
provided.
So I would like any one of the four of you who wish to
respond. You mentioned the risk factor that if we do not file
timely permanency or extensions, there is a fear that these
services are going away. Therefore, it becomes self-fulfilling,
because you do not schedule the next appointment because you do
not know whether it is going to be covered or not, or you just
do not set that up as your regimen.
So I would like you just to address for a few more minutes,
if you might, the importance of giving predictability in this
field. And although Congress thinks they can wait till December
of next year, what are the consequences if we do not timely
express this policy as a permanent policy?
Dr. Wallace. Sure, I can certainly start. So I think that
making telehealth permanent is very important. It is important
for our health system. I was involved in our 3- to 5-year
strategic plan for virtual care, and as we are thinking about
the plan, it is really hard to understand whether or not
telehealth investments should be made, because we do not know
whether or not it is going to be covered after December 31,
2024.
The other thing is that, if we are going to wait, what will
we be waiting for? I mean, there have been thousands of studies
that have been completed since the beginning of 2020, and the
message is quite clear, just like you mentioned, that there is
no runaway health-care spending. Quality of care is not being
compromised, and there is an improvement in access.
I do not think more studies are necessarily going to change
that strong signal that is coming from everything that has been
done. There was a recent review from AHRQ that confirmed the
same thing too. So I think it helps us predict, and then it
also sends a strong signal to the commercial market that
telehealth is not just a temporary thing during the public
health emergency, but instead it is actually a natural
extension of health care.
Senator Cardin. Dr. Mehrotra, you already mentioned the one
point that Senator Wyden raised in regards to the regulatory
framework. Are there other areas that we should be looking at
to make it easier for providers to provide telehealth services
or for patients to receive them, other than just the permanency
of the current provisions?
Dr. Mehrotra. I think there are a couple of other areas
that have been areas of frustration for the clinical community.
One was already touched upon, so I will just emphasize it right
now, which is the inability to prescribe certain medications
for opioid use disorder.
We have, as all of us are aware in this room, a horrible
opioid crisis. Many people are dying, and we have effective
medications. But the uncertainty that currently remains right
now about whether we can prescribe those medications via
telemedicine, I think is another major issue.
I know there has been a lot of debate about that topic, but
I think it is time for the DEA to move on this topic.
Senator Cardin. Dr. Wallace, I see you are nodding your
head. Anything further you want to add to that?
Dr. Wallace. I cannot agree more, and it is not just
Suboxone. I do not think anybody really agrees with the idea of
opioids and benzodiazepines being prescribed over telehealth.
But if you look at seizure medicines--so imagine yourself with
a seizure disorder. We now take away your driver's license for
6 months because you are not supposed to drive when you have
been diagnosed with a seizure disorder, and all of a sudden, we
cannot prescribe you medicines over telehealth because you have
to be seen in person. Almost all anti-seizure medications are
controlled substances.
So things like this make no sense when you realize what we
can do over telehealth, and for regulations' sake we will not
be able to unless the controlled substances are allowed to be
prescribed over telehealth.
Senator Cardin. Thank you.
Senator Daines?
Senator Daines. Thank you, Mr. Chairman.
Dr. Ellimoottil, you made the comment about strategic
plans. It is awfully hard to make a strategic plan when the
greatest threat is the uncertainty of Washington, DC. It
becomes ``plans'' plural versus ``plan.'' So, thank you for
that push. We need to kind of fish or cut bait here, and that
is why we are talking about permanency. We need to do it and
hopefully make your strategic planning a little more efficient.
I want to go back to this workforce question. I was
chatting with our witness, Ms. Perisho, earlier about the
workforce shortage that we are seeing with nurses and health-
care practitioners. Stress and burnout in fact amongst
caregivers have intensified during the pandemic. The numbers we
are seeing: an estimated 100,000 nurses left the profession in
2021. The Nation faces a projected shortage of up to 124,000 by
2034.
So our hospitals will need to make efforts to support,
retain, recruit caregivers. But the bottom line is, they do not
have enough caregivers today. There are not enough people in
the pipeline to care for an aging population with more complex
conditions.
Ms. Perisho, we chatted about that in my office earlier
today. Given your experience with telehealth, particularly in
rural and frontier areas, how can telehealth be leveraged to
address the severe workforce shortage facing health care today?
Ms. Perisho. I think it is looking at hybrid solutions, and
when I say ``hybrid,'' I mean a mix of in-person care and
virtual care.
Nursing specifically, virtual nursing has come about since
the pandemic. There was a large shortage of nurses that you
just mentioned during COVID-19, and innovative nursing programs
have come to fruition that really can support the nurses and
the practitioners and take that level of stress off.
I think specialty care providing, allowing rural members to
have access to specialty care via telehealth, is going to be
cost-saving on the patient and also on the health-care side
because there are going to be reduced readmissions. I really
believe that by bringing in the virtual, you are going to
improve the quality of life of the practitioners and the nurses
too, which is going to decrease that burnout.
Senator Daines. Thank you.
I liked a comment that you, Dr. Mehrotra, made in your
testimony as we were listening. You made a recommendation that
telehealth services should be paid less than in-person visits.
I would like you to expand on that. That is an important
question, certainly, for the committee. If you could expound on
your view regarding pay parity, any concerns that lower
reimbursement may discourage providers from offering telehealth
services at all. You studied it. I would love your thoughts.
Dr. Mehrotra. Yes, I think certainly paying less is going
to decrease the use of telehealth and will obviously decrease
the spending impact it is going to have. But I think that
patients and physicians recognize the benefits of telehealth,
they see its value, and I hope with that--I do not think it is
going to eliminate its use. I think it will probably still be
used in the manner it is being used right now, which is for
patients who have difficulty accessing care, or as a quick
substitute for a follow-up visit, so people do not have to
drive 2 hours or so.
So I think it still has a valuable role, and I am not as
concerned about that issue, that it is going to eliminate
telehealth use.
Senator Daines. But you still have a pretty strong view
that there should not be pay parity? There should be a
difference, lower----
Dr. Mehrotra. I think there should be a pay difference. And
it also allows for greater efficiency in the health-care
system. We want to use our taxpayer dollars as effectively as
possible.
Senator Daines. I think we all agree that telehealth has
expanded patient access. I think the data is about indisputable
in that regard, to both patients and providers. These visits
are important for ensuring patients get the care they need in a
timely manner, without unnecessary barriers.
And I think the point was also put up today that--we talked
about rural areas. We have rural challenges. But if you are in
an urban area, it might take you a half-hour to drive three
blocks, or it might take a half-hour to drive 20 miles in
Montana.
But there has also been interest in ensuring this care is
high-quality. But assessing telehealth quality can be
challenging due to some of the data limitations.
Dr. Ellimoottil, I understand the University of Michigan
Institute for Health Policy and Innovation did a study to
assess quality of telehealth in Michigan by looking at rate of
available emergency department visits and hospitalizations.
Could you comment on this and other studies that have evaluated
telehealth quality?
Dr. Ellimoottil. Certainly. Thank you, Senator. I think
that is a great question. It is a hard question to answer
because the association between telehealth and quality really
depends on the condition. It depends on the type of telehealth
and then depends on the quality measure. But I can certainly
speak to that particular study.
When we looked at the use of telehealth among primary care
practices in the State of Michigan, we found that there was no
difference in the rate of hospitalizations and emergency room
visits, and there was no increase and there was no decrease. I
think similar findings have been found by MedPAC and the recent
AHRQ review too.
So that is the association between telehealth and ER
visits. But if you look at remote monitoring--we have a program
at University of Michigan called Patient Monitoring at Home
where we send patients home after a hospitalization for
congestive heart failure, for example, with kits and
monitoring.
What we found is that 70 percent of those patients had
reduced hospitalizations after they were sent home or after
they were started on the program. So it really does depend on
the condition, the modality, and the quality measure that we
are looking at. But across the board, I think that we do not
see any decreases in quality, and then there are improvements
in access.
Senator Daines. Thank you.
Senator Cardin. Senator Blackburn?
Senator Blackburn. Thank you, Mr. Chairman, and then thank
you to you all for being here. I really appreciate it.
You know, when I was in the House, I worked on the
telehealth issue. We had this legislation. We thought we were
going to get it in the 21st Century Cures bill; we did not. So
we moved it as a stand-alone, and of course once COVID hit,
everyone said we need to have telehealth on the books. So it
came in through the emergency health order. And being able to
make these waivers, the COVID-19 waivers, permanent is
something that I am hopeful we are going to be able to do.
What we have learned is that seniors, elderly, people with
complex medical issues, people who have their primary source of
care delivered at a great distance, they have really benefited
from this. One of you mentioned in your statement the increase
in access and the additional number of appointments that an
individual would have.
So I am doing what I can, and I know that Senator Cardin
and Senator Daines are doing what they can to work this issue
through to the end of the year and make it permanent.
Dr. Wallace, I want to ask you about this: CMS has a rule
that would require physicians to report their home address, and
let me get you to weigh in quickly on that. And, Dr.
Ellimoottil, I would like to hear from you on that also about
the significant concerns that may come from that, if you feel
like that is of a concern, having to have that. And then, if
that requirement had been in place during COVID, what would it
have done to access to care? So, Dr. Wallace, you go first.
Dr. Wallace. Thank you, Senator, for the question. So our
institution, when that rule was being evaluated--and it has
recently been addressed in the new PFS rule.
However, operationally we would not be able to do it. We
have 1,100 providers at UAB. We have residents, et cetera, and
they are providing health care in many locations. They could be
in their office. So one of the questions that came up is, if
they are not in the clinic but they are located in their
physical office across campus, do we need to report that
address? Is it the ``home''?
So there are so many operational hurdles in doing that. It
would be a major problem. The other thing was privacy of the
physicians.
Senator Blackburn. Yes.
Dr. Wallace. I think that many physicians would not
actually do telehealth and would opt not to do telehealth if
they had to report their address publicly.
Senator Blackburn. Well, and I would think that the
consistency of your permanent business address should be
sufficient.
Dr. Wallace. I agree.
Senator Blackburn. Dr. Ellimoottil, go ahead.
Dr. Ellimoottil. Thanks. I will be quick, because I agree
100 percent with those comments, that privacy has been a major
concern for us, as it was for the 100 organizations that sent a
letter to CMS to try to avoid this situation. And then also,
operationalizing it--we have 3,000-plus clinicians. We have
providers who see patients in multiple different locations. We
have providers who may travel, who may move or stay in
temporary housing. So I think, all in all, it is very difficult
to operationalize, and then the privacy concern is the other
issue too.
But I agree with your point about the policy option there,
which is where your patients are being seen in person, which is
where your expenses are. So my understanding is, a lot of this
has to do with payment adjustment. So it is where your patients
are being seen in person that is likely the best address.
Senator Blackburn. Yes; okay.
Dr. Mehrotra, I want to come to you on digital health and
chronic disease management. Some of the providers I have talked
to in Tennessee have said that patient compliance is always a
problem, and that patient compliance through COVID with
diseases like diabetes was much better because people had that
accountability of the telehealth, that they had to show up for
that virtual appointment.
And when you look at diabetes--and it is $327 billion a
year to treat this. Talk for a minute about the ability to use
telehealth and digital health for coaching, for education, for
pushing toward compliance.
Dr. Mehrotra. Thank you, Senator Blackburn, and you are
raising a really important point. I will say briefly that our
research has highlighted that greater use of telehealth does
improve that major issue that you described: compliance with
people's medications.
It was also touched upon--remote patient monitoring--and I
think that is really another very effective way in terms of
helping patients, in terms of staying on their medications and
getting the care that they need. So these are some examples of
how this real innovation in digital health can improve chronic
illness in the United States.
Senator Blackburn. I have run out of time, and I know there
are others. I have a couple of other questions on that, but I
will submit those. I feel like this is an area we can choose to
put some emphasis on and expand. Thank you.
Thank you, Mr. Chairman.
Senator Cardin. Thank you.
Senator Cortez Masto?
Senator Cortez Masto. Thank you. Thank you, Mr. Chairman,
and to the ranking member. Like my colleagues, I support
telehealth services. I think they should be permanent, for the
very reasons that you are all saying, and there are other
barriers that we have to address.
Earlier this fall, I joined with Senators Warner and Thune
in sending a letter to the DEA about using telehealth to
prescribe controlled substances, just what you have been
talking about, including medications for mental health and
addiction treatment. We expressed our concern about the
approach DEA proposed this spring, including the requirement
that the patients see doctors in person to get the
prescriptions. We also strongly encouraged the DEA to move
forward with creating what they call a special registration
pathway as an alternative to these restrictions.
My question for the panel is, one, in 2023, in the proposed
rule, the DEA briefly discussed why they rejected the special
registration idea, and they argued that the process would be
too burdensome for both prospective telemedicine providers and
patients.
I want to open that up to the panel, number one. Do you
agree, or should we be looking at something to address these
concerns?
Dr. Mehrotra. Thank you, Senator. You are raising a key
point, and we have written about this topic. But the reasoning
that the DEA provided does not make any sense to me. I do not
think that the risk--you know, asking a physician or any other
clinician to go through that registration process seems very
reasonable. If that is a mechanism by which that clinician can
treat patients using telemedicine, I think it is a great
option. So I disagree with the DEA on this.
Senator Cortez Masto. Thank you, Doctor.
Dr. Ellimoottil. I agree. And if I could just make a quick
comment on that. So, I think if the DEA process is not made
burdensome, if they make it easy, I think that it will not be a
problem. I think it is much more burdensome for us to
operationalize the in-person requirement that the DEA was
initially putting in that proposed rule.
When that proposed rule came out, we sent that out to all
of our providers, just to give them a heads-up about what was
coming down the line at the end of the public health emergency,
and we had dozens of emails back from health-care providers
about nuances to that rule that just were not written out.
And I think it is very difficult and hard for us to
operationalize the in-person requirement. And in a lot of ways
an in-person requirement is creating a clinical guideline, kind
of out of thin air. I think that the registration process would
be much better, and then I do understand the need for avoiding
fraud and abuse. I think if we take a framework like the Office
of Inspector General has, which is looking back and identifying
patterns of fraud and abuse, I think we can handle this and be
able to prescribe to Medicare patients in a very safe way.
Senator Cortez Masto. Thank you. And that was my next
question, because I know the requirement was an in-person
visit, and that was the way to try to protect against fraud and
diversion in telehealth, including for prescribing of
controlled substances.
But then my next question to you is, does that really
address those issues, and if it does not, how do we address
those? What are the recommendations to address the concerns
that the DEA has with fraud and diversion? I am going to open
it up to the panel. So I do not know if anybody wants to----
Dr. Ellimoottil. Certainly. And so I think for a lot of
areas where we think fraud and abuse can run rampant, I think
the perspective that we should have is, instead of creating
guard rails prospectively, we should adopt a framework that the
Office of Inspector General has outlined, in terms of
identifying patterns of fraud and abuse, and sort of look
retrospectively, investigate those issues, recreate the
framework if necessary, once the investigation is done.
I think that will kind of lead to a much better sort of
check on fraud than creating these prospective guard rails that
lack clinical evidence.
Senator Cortez Masto. Thank you.
Dr. Wallace?
Dr. Wallace. Yes. I cannot agree more. Just because this is
telehealth does not mean that it is different than in-person
ways of monitoring fraud and abuse. So we already have a way to
monitor fraud and abuse with opioid prescriptions for in-
person. Those prescriptions are monitored by the PDMP. We have
to check that routinely. We get a report once a year on our
prescribing patterns. So the question for me is, why isn't the
way that we currently monitor opioid prescriptions in-person,
why is that not good enough for telehealth?
Senator Cortez Masto. Yes.
And now I want to address the concerns with audio-only as
well. I support audio-only, and I know there is also that
concern with abuse as well. If we are really trying to open up
this access at all of these levels and give the patients
choices, we would want to include that, but guard against any
type of fraud or abuse; correct?
Dr. Wallace. Absolutely.
Senator Cortez Masto. And is there a way to do it?
Dr. Wallace. I think at the heart of this it is, what are
we trying to achieve? Right now, we are trying to achieve a
reduction in overdoses. Our State saw an 11-percent increase in
overdoses. Why are we putting any barriers in front of the
patient to get care for their addiction?
Senator Cortez Masto. Thank you.
Thank you, Mr. Chairman.
Senator Cardin. Well, thank you for your questions. I
thought that was very helpful for the in-person visit issue,
because that has been one of the major areas that we have been
trying to clarify and make permanent. So, thank you for your
questions on that.
So, let me get to one other area, and that is the audio-
only versus the video and audio. I support that. Let me start
off with where I am on it, because I know that there are
communities and areas and households that do not have reliable
video, so audio is going to be the only service that they are
going to be able to get, if they are going to be able to use
telehealth. But I just would like to get your view as to
whether there is a difference in certain practices--where video
becomes a more important ingredient for telehealth--that we
should be aware of.
Our own experiences during COVID, all the Zooms that we
were on or the videoconferencing we were on--a lot of us would
have liked to have turned off our cameras, but we thought that
we were obligated to keep our cameras on because of the
interaction. Is there a difference in the quality of care
because of the personal interaction of a video, where you do
not have that on audio, and are certain practices more
susceptible to that differential? Any stuff you can give us.
Ms. Perisho. Thank you, Senator. I will take this one.
Senator Cardin. Yes.
Ms. Perisho. I think that there is, and I think it should
be up to the practitioner to decide what is appropriate for
audio-only versus video. I think it depends on if there is an
established relationship with the provider and a patient first
and foremost, and I will turn it over to my colleagues to
answer.
Dr. Wallace. Thank you, Senator. As far as the difference
in quality, I agree it should be up to the physician to
actually decide. One of the things that we need to understand
is that we are still held to medical liability.
So, if we actually offer an audio-only phone call, and we
cannot diagnose or help the patient over audio-only, and there
is a poor outcome, we are held accountable. So providers who
actually understand telehealth--which now after COVID I would
say all providers do--have to make the decision, can I do this
visit over audio-only or do I need video?
And if the answer is ``no'' to either of those, we actually
can pivot and say this is something that needs to be handled in
person.
Senator Cardin. Let me challenge on this for one moment. If
you are a provider and the option is audio-only or no service
because the individual does not have reliable video, you may
feel more comfortable with the video aspects, but you do not
want to deny access to your patient.
So I guess my point is, I recognize there is a threshold,
and you are responsible for that threshold. But is there a
difference in the quality area between audio-only or visual?
Dr. Wallace. I think it depends on what you are treating. I
will give you an example of a clinic that I had last week. I
take care of rare disease. Those patients travel hours to see
me. So, in the middle, I tried for 5 minutes to get a patient
on video.
If audio-only was not covered, I would have had to stop the
video and say, ``You are going to have to come in person.'' But
now I have to schedule them for my next scheduled appointment,
which may be 3 months away because there are no clinic slots.
So what I was able to do is pivot to the audio-only.
Now in nephrology, we are largely lab-based. So I can still
review all of the patient's labs. I can review all of the
patient's imaging that they have had. So there are a lot of
things that I can do that the patient was able to benefit from,
even though they were not able to get on video.
Senator Cardin. Of course, I could make a point here for
wider broadband, affordable broadband in everyone's household.
So that is another part of that, and as I understand it, in the
infrastructure bill, there was a significant increase in the
capacities in our country for video as well as audio.
So that may be a problem that we are solving, but as I said
in the preliminary to my question, I support audio. I just
really want to know if it is appropriate to do both audio-only
or audio with video. Is there a difference in the quality or
the comfort level from the patient's point of view or from the
physician's point of view? Have there been any studies that
would reflect whether we should be working a little bit harder
to make sure there is greater access to broadband?
Dr. Mehrotra. Maybe I will just jump in here. So first, I
mean we have to recognize, if it is audio or nothing, audio is
going to be better there. But I also have to acknowledge that
audio visits--many clinicians are not sure about the quality
that they are providing. They would prefer to do video. At
least in some of the work we have done, they perceive that a
video visit provides a bit better care. And I am worried about
creating a two-tiered system in the future, where the rich get
the video calls and the poor get the phone calls. So I do want
to make sure that we are really pushing hard to make sure video
visits for everybody are available.
And the reason I bring that up is because, while we have to
acknowledge the barriers the patients face, also from our
research we are seeing circumstances where it is driven by
provider preference. Some providers are not providing. You have
to offer the video visits, and you have to work with the
patients to try to make sure you address those barriers.
I think that we need to really push on the provider
community to make sure that they are offering video visits and
working with patients to make sure they overcome those
barriers, because I am worried a little bit about the default
of going to phone calls when a video visit could have been
better.
Senator Cardin. Thank you.
Senator Cortez Masto, anything further?
Senator Cortez Masto. I have one final question. And just
to jump back to that, Dr. Mehrotra, is that why your
recommendation is for telehealth services, that you would pay
less for telehealth services than you would for in-person, is
that right, to address some of that, or incentivize more of the
in-person, to have the provider do the in-person when
necessary? Or why would you make that recommendation, I guess?
Dr. Mehrotra. Yes, my recommendation--thanks for raising
that and clarifying that. It is a really key point. My
recommendation was largely based on the way that the system is
structured, less on incentives, but rather simply based on what
we need to reimburse clinicians based on the cost to provide
that care. And these visits are cheaper to provide, so we
should reimburse appropriately.
Senator Cortez Masto. Right. And then finally, can I just
jump on a separate subject really quickly? So this Congress,
Senator Daines and I led the Telehealth Expansion Act, and it
is a bipartisan, bicameral bill that would make permanent a
CARES Act provision that allows employers the flexibility to
offer telehealth services below the deductible to employees
with a Health Savings Account so that employers can offer
telehealth services to employees regardless of the type of
health plan they are enrolled in. To me, this is common sense.
This ensures that families in the private market or that are
employed by large employers, that families could access vital
telehealth services, including virtual primary care and
behavioral health. We have not even talked about that.
Behavioral health, mental health services are just as
important.
So, Dr. Ellimoottil, I know this hearing is focused on the
Medicare program, but can you speak to the importance of a
bipartisan proposal like that, that lowers the access to care
barriers for primary care, for telehealth services as well, and
the benefits to patients, particularly in States like Nevada,
where we have an urban core as well as large rural populations
that literally cannot access some of these services?
Dr. Ellimoottil. Sure; thank you. So, I do think in
general, any policy that expands access to telehealth is a good
thing, and I am not very familiar with that particular policy.
But I do think that it creates access, and that is important.
When we looked at the State of Michigan and found areas
where there are provider shortages, we found that telehealth
has, especially for mental health, actually allowed providers
to provide care into the homes of these provider shortage
areas.
So I think that I am supportive of any policy that is
expanding telehealth.
Senator Cortez Masto. Thank you.
Thank you, Mr. Chair.
Senator Cardin. Senator Barrasso?
Senator Barrasso. Thanks, Mr. Chairman.
Ms. Perisho, could you talk a little about telehealth? I
mean, in Wyoming, like Montana, it is an important access point
for care. It really does help our Medicare beneficiaries, for
especially services.
I think that in 2021, the Department of Health and Human
Services reported about 29 percent of Medicare telehealth
services in Wyoming were provided by an out-of-State provider,
which is of concern if there is some kind of a crisis where you
actually need hands-on care right there.
HHS has stated that that high rate of outsourcing is likely
reflecting a shortage of availability, especially since that is
exactly right. I am concerned about relying too heavily on
telehealth. It is important, it helps us, but are we worried
about the issues? So, given the challenges you face in Montana,
we face in Wyoming, how are you dealing with it from the
standpoint of work shortages, workplace shortages?
Ms. Perisho. You know, we get a lot of questions. We talked
a little bit about the interstate licensing and cross-border
licensing. I think that is one of the challenges: finding
specialists licensed within that State.
In terms of workforce shortages, there are, since the
pandemic, multiple providers that are providing only services
via telehealth and are licensed in multiple States. And until
we have sort of a solution to the cross-State licensure, I
think that is the solution for now.
Senator Barrasso. Yes.
I think, Dr. Mehrotra, in your opening statement you talked
about how 5 percent of physicians have closed their physical
doors to become full-time telehealth providers. So, I do
believe there is real value as well of having telehealth, but
also the direct hands-on patient care component of it.
So you know, it is interesting, having practiced orthopedic
surgery for 24 years. I feel I could go back and do the
surgery. I am not sure I could do the computer work or the
technical aspects of filling in all the spots. So the latest
estimates are that doctors are now spending about 20 percent of
their time inputting patient information into electronic
medical records.
In our office, we did electronic medical records before it
was a thing. We wanted to be on top of things. The Economist
magazine, in their annual health barometer, said one of the
greatest barriers they identified was that solutions are not
always designed with the need of clinicians and patients in
mind.
So I find it especially true with increasingly complex,
fragmented systems required to provide telehealth. So, what
existing telehealth services do you see more as barriers rather
than solutions? Do you see those out there in some ways?
Dr. Mehrotra. Senator, I think you are raising a real key
issue here related to the administrative burden in the
practicing of medicine. And I do think that we do have to be
careful. One of the reasons that I have been enthusiastic about
expanding geographic rules and conditions is because right now,
there is a little bit too much thought process and
administrative burden. Oh, does this telehealth visit get
covered? Oh, that is mental health, but oh, maybe it is
substance use.
You know, there are a lot of nuances there which do not
translate well to clinical care. So I do think we need to be
thinking about the administrative burden when we are thinking
about telehealth policy. It is a key issue.
Senator Barrasso. Yes, because if they are spending that
much time saying, ``How do I fill this out?'', it is time when
they are not in direct patient contact and doing what they want
to do, if they are still trying to get home to be with family,
friends, do other activities, and not feel overwhelmed or
burned out, which is a key part of it. So thank you.
And, Dr. Wallace, if I could, you and I are both invested
in improving patient care, improving outcomes. There are 60 of
us in the Senate who have cosponsored the bipartisan CONNECT
Act. Senator Schatz from Hawaii is the original sponsor. A
number of us have cosponsored.
It addresses patient care outcomes. It allows for remote
patient monitoring for people with chronic conditions. Remote
patient monitoring, I think, is one of the most innovative and
cost-effective solutions to chronic care management. It is
trying to be used around the world where the technology is
available.
So, as somebody who specializes in the treatment of chronic
conditions, can you discuss how using remote patient monitoring
for your Medicare patients would impact your ability to treat
them?
Dr. Wallace. Thank you, Senator. I 100-percent agree with
you. So, the University of Alabama at Birmingham has a remote
patient monitoring program that we started in 2018. What we did
for Medicare beneficiaries, specifically our Accountable Care
Organization, which has 17,000 beneficiaries, is we actually
identified patients with heart failure, chronic kidney disease,
diabetes, hypertension, and congestive heart failure. We
subjected them to remote patient monitoring and ended up saving
$1,300 per member per month using remote patient monitoring.
Senator Barrasso. Per member per month?
Dr. Wallace. Per member per month. The other thing is that,
when you look at the number-one causes of end-stage renal
disease in this country, they are hypertension and diabetes.
So, we have over 400,000 end-stage renal disease patients
at a cost of $80,000 per patient per year. So with remote
patient monitoring, if we are able to address hypertension--and
in our program we were able to reduce the patient population's
systolic blood pressure by 9 millimeters of mercury in the
first 45 days. If we are able to address chronic kidney disease
from hypertension and diabetes and get them under control,
maybe we can reduce the amount of end-stage renal disease,
which ultimately--even one patient off dialysis will pay for a
whole lot of remote patient monitoring.
Senator Barrasso. Well, if you had that kind of a decrease
across the board of the systolic pressure, you do not know how
many strokes you have prevented as well in the process, which
is an additive effect.
Dr. Wallace. Absolutely.
Senator Barrasso. Thanks, Mr. Chairman.
Senator Cardin. Thank you.
Senator Whitehouse?
Senator Whitehouse. Mr. Chairman, I think it is very unfair
that I have to follow an actual doctor in this conversation.
Senator Cardin. Let the record reflect that The
Washingtonian magazine a number of years ago listed the
smartest member of the U.S. Senate as Sheldon Whitehouse. I
rest my case.
Senator Whitehouse. It is Barrasso. It was a misprint.
[Laughter.]
I am glad you all are here, and I wanted to make one point
and then ask a question.
I am a big advocate for moving away as fast as we can from
fee-for-service, and moving toward value-based care. I am a
particular fan of freestanding ACOs, because we had two very,
very good ACOs operating in Rhode Island: Coastal Medical and
Integra.
I think that when the incentives line up for doctors to
provide the best care rather than the most care, then things
like telehealth can actually happen fairly naturally. In fact,
we have experience of ACOs being willing to install telehealth
machinery in patient's houses because it works better, without
having to get a special--you know, it's just part of the
overhead essentially.
So I think this represents one of many areas in which, if
we solve the fee-for-service billing nightmare and treadmill, a
lot of good things will come. But I want to talk specifically
about the TREATS Act and opioid and substance abuse treatment.
The TREATS Act is mine with Senator Murkowski, but I think
there are six members of this committee who are cosponsors of
it. And we have had, I think, 434 deaths from overdoses in
Rhode Island, so it is really important to get the services out
there that people need.
One of our service providers is an excellent group called
CODAC--spelled with Cs, not Ks like the old camera company--run
by a woman named Linda Hurley, who is very, very good. And
there is a client of theirs, a patient of theirs, who works,
and the time that she can get for her conversations with her
treatment specialist are her lunch hours. Now, if she had to go
someplace and sit in the waiting room and wait and fill out the
clipboard form for the umpteenth time and then hope to be seen
and all that, it would not happen. Her sobriety is supported by
these regular conversations she has, and they happen because of
telehealth. Otherwise, it would not work. She is a busy person.
She has a busy schedule. Her employer is very strict about her
being available when needed. So that is her window, and
telehealth makes it happen for her and keeps her supported in
her sobriety.
So, I guess I just wanted to ask Dr. Mehrotra a little bit
about how you think telehealth is an advantage in dealing with
the current opioid crisis and the terrible toll that it is
taking.
Dr. Mehrotra. Thank you for that point. I just wanted to
emphasize the issue that we have an opioid crisis, and
telehealth can be that mechanism to get that care for those
patients where it is very difficult for them to get to their
clinician--you told us about that story--but also where there
is no one you can go to nearby, that you can drive to to get
that care that you really, really need.
I also wanted to tie it back to what you were describing
before, really briefly, which is that I have seen some really
innovative----
Senator Whitehouse. I might talk about rural Rhode Island,
but I think Senator Thune might think that I was kidding.
Dr. Mehrotra. There are some new payment models that are
being used for opioid treatment programs, OTPs, as well as for
opioid use disorder, where they are giving a monthly or weekly
payment and saying, look, clinician, you provide the care as
you need it, and let's not get into that administrative burden
of this visit or that visit. So, I think it is a really
exciting space for innovation, because we need it.
Senator Whitehouse. Yes. So you are actually tying my two
points together. The payment reform and available telehealth
make a really good combination in terms of serving patients and
reducing cost. You cannot do better than that. Thank you.
Senator Cardin. Senator Young?
Senator Young. Thank you, Mr. Chairman, and thank you to
our witnesses for being here today.
I have to say, even prior to the pandemic, I was hearing
from a lot of my constituents in Indiana--most of them rural,
but a fair number within a suburban or urban context--about the
benefits they were receiving from various telehealth options.
And during the pandemic, of course, it was a real lifesaver for
countless Americans.
Those flexibilities that made a number of the pandemic-era
telehealth services possible--and still many of which continue
today--have helped vulnerable seniors in my State. We still
hear quite a bit about it from others who increasingly, it
seems, are accessing care and benefiting from care in the
safety and comfort and familiarity of their own homes.
So I am really excited about the possibilities and the
future of telehealth services. I get frustrated at times about
some of the friction points, usually governmental in nature,
associated with a future deployment. So I will just--I have a
series of discrete questions, beginning with Dr. Mehrotra.
Doctor, what data or evidence has CMS or others collected
to determine what waiver should be made permanent, and is there
any additional data that, in your mind, should be reviewed or
collected as we think critically about creating an environment
where telehealth can continue to be taken advantage of?
Dr. Mehrotra. Well, Senator, thank you very much for that
question. First, I do think that, currently, CMS has a process
that is set up that can be improved to kind of determine--where
groups will come to them, say for example physical therapy or
others, about how we need to expand, what is the evidence base?
And I think we can continue that.
But I think the larger point that I think your question
raises, which is so critical, is this is a rapidly changing
place, telehealth today versus 5 years ago versus 10 years ago.
And we are going to need to be monitoring this extremely
carefully, because new innovations like artificial intelligence
and other things are coming down the pike.
So we need to be constantly monitoring this area, to
understand how to best deploy telehealth.
Senator Young. And do you feel like we have mechanisms in
place to engage in that, sort of those iterative improvements,
that constant monitoring, that will be helpful to innovation
and deployment moving forward?
Dr. Mehrotra. Yes, I do think that as much flexibility as
can be provided to CMS and Medicare for that space is really
critical, because there is going to be, and there also needs to
be, investment from the agency in terms of determining how
telehealth is going.
Senator Young. If you look at current technology, current
practices--I noted your discussions of what waivers should be
made permanent. That is normally what we ask you. But are there
any regulatory changes that you recommend that Congress and the
administration not make permanent as it pertains to telehealth?
Dr. Mehrotra. To me?
Senator Young. Oh, yes. And then, Dr. Ellimoottil, we will
go to you next.
Dr. Mehrotra. One area I do not feel that we need to make
permanent or make a move on right now is audio-only visits,
where I feel like we can continue to push on the provider
community to provide a video visit, because I feel like that is
the real place where we need to improve care.
Senator Young. Makes sense.
Yes, Doctor?
Dr. Ellimoottil. Thank you, Senator. That is a great
question. I actually--I do disagree, and I do think that audio-
only is necessary and should be included. I think the package
of deregulation that occurred and the flexibilities that are
currently available are good, and I do not think that there is
any guard rail that is not in the current flexibilities that
necessarily needs to be added in.
Senator Young. Thank you. Disagreements are always
interesting though, so I am going to ask you to explain that,
please.
Dr. Ellimoottil. Yes. I mean, as we talked about earlier in
the testimony, I actually call coverage of audio-only one of
the four pillars that we need to prevent the slow death of
telehealth over time, because audio-only coverage, audio visits
occur when providers are connecting with patients and the
patient cannot connect or does not have the ability to connect,
and then you have to sort of flip that appointment to an audio-
only visit.
So, when I am discussing kidney stone surgery with a
patient, whether it is in-person, video, or audio, I am
delivering the exact same care. So that is why I think it is an
important element.
Senator Young. Okay. Does anyone else want to address that
question? Dr. Wallace?
Dr. Wallace. I agree with Dr. Ellimoottil. Not only do we
need audio-only coverage, we also need coverage of telehealth
at parity. If telehealth is not covered at parity with in-
person--the physicians have to keep the door open. So, in order
to keep those doors open--if I am doing nine in-person visits
and one telehealth for my patient population, which is largely
rare disease--I need that to be covered on par with in-person,
or what will happen is, you will just make a decision. The cost
of nursing has gone up. The margins in health care have gone
down, and what will happen is, you will be forced to make a
decision, and the death of telehealth will ensue, as Dr.
Ellimoottil has said.
Senator Young. It seems to me that if you can discern, with
a high degree of confidence or reliability, that telehealth
services offer roughly the same outcomes, you offer the same
compensation. If instead, your health outcomes are 75 percent--
which they are not in every context, so I want to be very
clear--but then you might think about an access to care versus
a quality tradeoff. So it might get a little more complicated,
but my instincts are, because you are a doctor and because what
you said was intelligent, to agree with you. But I am out of
time, so thank you, Mr. Chairman.
Senator Cardin. Senator Thune?
Senator Thune. Thank you, Mr. Chairman, and thanks to you
and Senator Daines for holding this important hearing on
telehealth. In South Dakota, we have long understood the value
of telehealth, and the pandemic not only demonstrated the
importance of telehealth, but also provided an opportunity to
gather real data from its use. I think that helped to
illuminate even more the potential way in which we can deliver,
particularly mental health services, via technology. While we
have extended the telehealth flexibilities in Medicare until
December 2024, we need to work toward permanent telehealth
policies in Medicare, such as those in bipartisan legislation
that I have led with my colleagues, like the CONNECT for Health
Act and the Telemental Health Care Access Act.
Dr. Mehrotra, telehealth has proven to be an essential tool
for providing access to mental health care. Unfortunately, I am
concerned that we enacted a policy in 2020 to require an in-
person visit for telemental health visits in Medicare.
Telehealth offers an opportunity to increase access to
mental health, but an in-person visit requirement seems
arbitrary, and I think is going to make access even more
inequitable. So last year, Senator Cardin and I led a working
group, as part of this committee's mental health-care
initiative, to take a deeper look at how to improve telemental
health care.
Our legislation proposed removing Medicare's in-person
requirement for telemental health services. From your research
on telehealth, can you tell us more about the challenges an in-
person requirement would have for patients seeking mental
health services, especially for those patients in rural areas?
Dr. Mehrotra. Thank you, Senator. I think it is a really
important issue. So, the one thing that we have done some work
on is trying to understand how often does this in-person visit
occur right now, before a first telemental health visit.
It is pretty rare; less than one out of five times in that
6 months in the current regs that we see a visit. I emphasize
that point because it is going to be a big change in care if
that in-person visit requirement goes into effect, and it is
also clear to me that clinicians do not see that it is really
critical.
And so, I think that kind of data helps support what I
think a lot of us have spoken about, which is that this in-
person visit requirement should be eliminated, because I do not
think it is adding value in any way, and it is also deterring
people from using telemental health to access communities where
there are no mental health specialists for them to see locally.
Senator Thune. Yes; thank you.
Ms. Perisho, first I am excited to hear about the work on
telestroke. In 2017, Congress passed my legislation, the FAST
Act, which eliminated the originating site restrictions for
telehealth services to diagnose and treat stroke.
However, as you outline in your testimony, additional
originating site and distant site restrictions still exist,
preventing patients from accessing care. During the pandemic,
Congress suspended Medicare's distant site requirements for
Federally Qualified Health Centers and Rural Health Clinics.
In South Dakota, that enabled our health clinics to
strengthen local access to care by building telehealth
connectivity between remote, rural, and frontier sites. Could
you discuss a little bit more the importance of allowing
Federally Qualified Health Centers and Rural Health Clinics to
serve as distant sites for telehealth?
Ms. Perisho. Yes. Thank you for that question. I have
stated in my testimony that FQHCs and RHCs should be distant
site providers because a lot of times they are that first touch
of the patient when they are having a health crisis, and they
support so many facets of health care in terms of the primary
care, behavioral health, dental, and so on and so forth. So I
believe it is very important for FQHCs and RHCs in rural areas
to be distant site providers.
Senator Thune. Okay.
Let me just ask, come back to Dr. Mehrotra, and if I could
get you to comment a little bit on your research and the
evidence that we now have on the quality of care provided over
telehealth. Can you summarize that maybe a little bit?
Dr. Mehrotra. There has been a lot of research that has
been done on this topic, Senator, and so I think it is a really
key point. In my testimony, I touched upon some recent work
that we have done, which has found that the greater use of
telehealth by a health system or a clinic is associated with
some improvements in health. The one that I think is maybe
particularly important is chronic illness medication adherence.
Often our patients do not take their medications, and having
that telehealth availability appears to have enough touch
points to maybe increase their use of medications, which will
have some long-term benefits. So I think it is a real key
quality area.
Senator Thune. And do you think with all the new data that
we have, largely through the pandemic, we have more sort of
real-life test cases for that broad adoption? And you have
talked about--I think in your testimony too--that in the past,
some patients have worried about the quality of those visits
compared to in-person visits.
But with now just the amount, the volume if you will, of
the data available, and an opportunity to analyze the impact of
that, particularly during the pandemic, how do you see--I guess
I want to ask--at least in the future, folks in government
agencies that deal with these issues recognizing the value that
telehealth delivers, and not just in making available mental
health services, but also the quality of those services?
Dr. Mehrotra. Yes, Senator. This was emphasized by other
panelists, so I want to echo what they said, that in the
pandemic, with the greater use of telehealth, we have seen
little evidence or no evidence that it has hurt quality of
care.
So I think it is a positive that we can go back to the
American public and say, ``Look, this expansion really did
improve the health of Americans.''
Senator Thune. Okay; good.
Thank you, Mr. Chairman.
Senator Cardin. I just really want to acknowledge one more
time Senator Thune's leadership, us working together on a task
force to look at mental health. We had telehealth, and I think
we had the first recommendations out of any of the task forces
to really expand telehealth for mental health services.
So, it was a pleasure to work with you, and a lot of our
recommendations were implemented. I think the permanency of the
provisions we have here today would further implement the
recommendations from our task force.
This has been a great panel. Thank you all very much for
your dedication to this field. I think your comments about this
being a field where you are going to see--we have seen
significant change over the last decade. We will see what
happens in the next decade, because I think you will see this
will be evolving, and your suggestions, I think, help us in
trying to deal with this issue.
I want to keep the record open until the end of business on
Friday. Next week we are in recess with the Thanksgiving week,
so it is a little bit earlier deadline for our committee. But I
would ask the cooperation of our members who have questions for
the record to submit them by the end of this week. And if there
are questions asked, if the panelists would respond promptly,
we would certainly appreciate that.
And with that, with our thanks, the hearing will be
adjourned.
[Whereupon, at 4:05 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Hon. Steve Daines,
a U.S. Senator From Montana
Thank you, Mr. Chairman. Before I begin, I want to thank you for
your leadership in this subcommittee this year. It's been very
productive--we've had some great hearings on relevant health policy
issues, and I look forward to continuing to work together next year as
well.
I'm glad we're turning our attention to the topic of telehealth, as
we have some crucial decisions to make when the Medicare pandemic-era
waivers expire next year.
For our conversation today, we are fortunate to be joined by a
panel of some of the sharpest telehealth minds our country has to
offer. Thank you all for bringing your experience and expertise to our
discussion, and also for making the trip to DC. I understand you've all
traveled a long way to be here--especially Ms. Perisho, from Whitefish,
MT.
For those who are not familiar with Montana's geography, Whitefish
is high up in the Northwest corner of the State--the gateway to Glacier
National Park. Thank you, Ms. Perisho, for being here with us to
discuss this very important topic.
As we all know, the COVID-19 pandemic drastically changed our
health-care sector in America and our understanding of health-care
delivery. Telehealth, which was underused and understudied prior to
2020, suddenly became a critical means of delivering health-care
services to patients.
Through a series of agency waivers and bipartisan legislation, the
Medicare program pivoted over the last few years to allow for greater
and more flexible telehealth access for beneficiaries. Since
implementing those flexibilities, we've seen the advantages telehealth
offers and the expanded access it provides.
In rural States like Montana, telehealth has completely changed the
game in terms of health-care access. At our rural health hearing
earlier this year, I highlighted that two of the most challenging
barriers to accessing care in rural States are distance and
transportation.
With the ability to receive care virtually in the home, patients no
longer have to travel multiple hours to see their providers, and the
incorporation of audio-only telehealth has increased access in areas
without sufficient broadband infrastructure.
Telehealth also played a notable role in meeting the mental health
needs of patients during and after the pandemic, including in the
Medicare population. Even after the height of COVID, CMS data report
that the share of Medicare services conducted via telehealth remained
the highest for mental and behavioral health specialists.
Sadly, we are all aware of the mental health crisis in our country.
Just last week in this committee, I joined my colleagues in marking up
the BETTER Act, which contains significant proposals to expand access
to mental health and substance use disorder services in our Federal
health-care programs. As the pandemic demonstrated, telehealth can help
us bolster mental health services and address some of the access gaps
throughout the country.
It's safe to say there is no going back now that we've seen how
transformative telehealth can be. The question is how Congress will
shape the future of telehealth when the Medicare waivers expire at the
end of next year. Policy decisions such as originating site
eligibility, appropriate reimbursement, and in-person requirements will
need to be addressed, and we are here to begin considering some of
those policy questions.
My colleagues on this committee and I have demonstrated our
commitment to telehealth through various pieces of legislation which
support and expand upon the flexibilities Medicare beneficiaries have
come to rely on over the past few years. My hope is that today's
conversation helps to further inform the committee as we deliberate
telehealth permanency.
Thank you again to our witnesses--we appreciate your continued work
and dedication to this subject, and I look forward to hearing from you.
Thank you, Mr. Chairman.
______
Prepared Statement of Chad Ellimoottil, M.D., MS, Associate Professor
and Medical Director of Virtual Care, University of Michigan
I would like to begin by expressing my gratitude to the members of
this subcommittee for this opportunity to discuss the current and
future state of telehealth in the United States.
Telehealth took off during the early stages of the pandemic, thanks
to essential flexibilities such as the removal of geographic
restrictions and coverage for audio-only telehealth. In MedPAC's
survey, 90 percent reported satisfaction with their telehealth visits.
Currently, telehealth accounts for 10 percent of office visits, a
rate that has been stable since July 2021 and is anticipated to remain
so until December 31, 2024. However, I am concerned about a potential
decline in telehealth usage after that date, which could occur either
rapidly or gradually. Preventing both the fast and slow death of
telehealth depends on the actions of Congress and CMS.
The fast death of telehealth could happen if the originating site
and geographic restrictions are reinstated. If that were to occur,
there's no doubt that we could revert to the pre-pandemic levels of
telehealth usage, where fewer than 1 percent of health-care providers
and patients were utilizing telehealth services.
The slow death of telehealth may occur when patients and providers
become increasingly frustrated by regulations and unexpected bills and
ultimately stop using telehealth. Four key factors could contribute to
this slow decline if left unaddressed:
1. Lack of coverage alignment among payers--Medicare sets the
standard that many commercial payers follow. If Medicare
continues to view expanded telehealth coverage as
``temporary,'' commercial payers will reduce or eliminate their
coverage for telehealth services. This is already underway, and
we are witnessing the development of a fragmented telehealth
payment system that creates confusion for both patients and
providers. Imagine being a patient and not knowing whether your
insurance will cover a video visit, a phone call, or neither.
The path of least resistance for both patients and providers
would be to schedule the next follow-up as an in-person visit,
even if a video visit was clinically appropriate.
2. Loss of audio-only coverage--My personal research, along
with that of others, has shown that there is an obvious digital
divide. Recently, I experienced this myself in my clinic when I
attempted to conduct a video visit with a patient from rural
Michigan who was experiencing connectivity issues. After about
5 minutes of troubleshooting, I resorted to picking up the
phone and conveyed the exact same information about surgical
options for his enlarged prostate over the phone. Such
scenarios are quite common, particularly for Medicare
beneficiaries residing in rural and underserved communities. If
audio-only visits become ineligible for billing in the future,
health-care providers will not offer them and, as a result,
Medicare beneficiaries will lose this option for remote care.
3. Loss of payment parity--The prevailing narrative suggests
that the practice expenses related to telehealth visits are
lower than those for in-person visits, thereby supporting the
argument for payers to reduce reimbursement rates for
telehealth visits. While on the surface this narrative is
convincing, the reality is that unless your practice is
entirely virtual, it's unlikely that your practice expenses
have decreased. In a practice where only 1 out of 10 office
visits is virtual, health-care providers still incur the same
costs for maintaining a physical office, equipment, and
salaries of staff, such as clerks and nurses, who schedule
visits, collect records, and provide care between visits.
Practically speaking, these expenses don't decrease by 10
percent just because 10 percent of your visits are virtual.
4. Implementation of guard rails that lack clinical evidence--
While we all recognize the importance of preventing fraud and
abuse, implementing guard rails like mandating periodic in-
person visits for patients receiving telehealth services only
creates barriers to health-care access. In 2022, the Office of
Inspector General evaluated 742,000 telehealth providers and
found that only 0.2 percent displayed potentially fraudulent or
abusive billing patterns. There isn't a need to impose in-
person guard rails on the 99.8 percent of health-care providers
who use telehealth without exhibiting any patterns of fraud and
abuse.
Actions of Congress and CMS in these 4 key areas can help prevent
the slow death of telehealth after December 31, 2024.
I understand that there is appropriate concern both within this
committee and beyond that the permanent expansion of telehealth will
result in excessive health-care utilization and spending. Based on my
research and my experience overseeing telehealth at the University of
Michigan, I can confidently state that this is unlikely.
In my written testimony, you will find data that sheds light on
what researchers have learned over the last 3 years. While no single
study or report can definitively capture the entire impact of
telehealth on costs, quality, and access, I believe most researchers
would at least agree on these three points:
1. Telehealth expansion has not led to runaway health-care
spending or utilization.
2. Telehealth does not compromise quality of care for
patients.
3. Telehealth improves access to care.
In the end, making telehealth expansion permanent is about ensuring
that Medicare beneficiaries have choices in their care, whether it's
in-person, via video, or through a phone call. I applaud this committee
for its extensive efforts in making telehealth coverage permanent.
summary of studies on the impact of telehealth on cost, quality, and
access
Utilization and Costs
From July 2021 through December 2022, the proportion of
telehealth-based evaluation and management visits among
Medicare FFS beneficiaries has consistently hovered around 11
percent. (Figure 1, Ellimoottil 2023)
From March 2020 through December 2022, the combined total
number of monthly in-person and telehealth office visits has
not exceeded 2019 levels at any point. (Figure 1, Ellimoottil
2023)
There were greater rates of same-specialty in-person follow-
up in the 90 days after in-person office visits than after
telehealth visits. (Gerhart 2023)
The availability of telehealth has not led to additional
primary care visits; instead, telehealth is serving as a
substitute for specific in-person encounters, resulting in no
overall increase in primary care utilization. (Dixit 2022)
Patients who had visits for acute respiratory infections
were more likely to seek follow-up care within 7 days after
telemedicine visits (10 percent) compared to after in-person
visits (6%). (Li 2021)
Adjusted 30-day episode costs were lower for Medicare
patients who had initial telehealth visits compared to in-
person visits. These patients exhibited higher rates of 30-day
return visits but lower rates of imaging and laboratory
testing. Results are preliminary. (Ellimoottil 2023)
Total cost of care per beneficiary increased in 2021
compared with 2019 across all regions evaluated but increased
more in high-telehealth intensity regions. Conclusion:
``Greater telehealth use was associated with slightly increased
costs to the Medicare program.'' (MedPAC 2023)
Quality
Hospitalization rates for conditions such as congestive
heart failure and dehydration were lower in the second half of
2021. However, the rate of decrease in areas associated with
high telehealth use was slower. Emergency department visit
rates were not found to be associated with a region's
telehealth use. Conclusion: ``Greater telehealth use was
associated with little change in quality.'' (MedPAC 2023)
Practices that have high levels of telehealth use had
marginally higher overall hospital or emergency room visit
rates than low telehealth practices. (Li 2022)
AHRQ review of 165 studies reporting outcomes concludes:
``Across a variety of conditions, telehealth produced similar
clinical outcomes as compared with in-person care; differences
in clinical outcomes, when seen, were generally small and not
clinically meaningful when comparing in-person with telehealth
care.'' (Hatef 2023)
Beneficiaries were generally satisfied with the visits.
Forty percent of telehealth users expressed their interest in
continuing to use telehealth even after the pandemic ends.
(MedPAC 2023)
Access
Total clinician encounters per beneficiary were lower in the
second half of 2021 than in the second half of 2019, though the
decline was slower, on average, among high-telehealth-intensity
regions compared with low-telehealth-
intensity regions. Conclusion: Greater telehealth use was
associated with ``slightly improved access to care for some
beneficiaries.'' (MedPAC 2023)
Patients who are older, are African-American, require an
interpreter, use Medicaid, and live in areas with low broadband
access are less likely to use video visits as compared to
phone. (Chen 2022)
Patients who had at least one telehealth visit for opioid
use disorder were more likely to remain engaged in treatment
for at least 90 days, compared to in-person treatment. Staying
in treatment is key to reducing the risk for relapse and
overdose. Among those who had at least one telehealth visit,
those who were older (45-65+ years old), male, Black, or had
housing instability were more likely to have only audio-only
visits rather than video visits. (Frost 2022)
Interviews with behavioral health providers revealed that
they felt better equipped to meet their clients' diverse needs
after receiving the flexibility to offer telehealth services
when appropriate. Telehealth helped mitigate frequently cited
barriers to accessing behavioral health care, such as the lack
of transportation, missed work, and the need to arrange child
care. (Beck 2021)
Increase in overall and telehealth addiction treatment
utilization after telehealth policies changed during the COVID-
19 pandemic. There was no evidence that disparities were
exacerbated. (Palzes 2023)
Compared to patients with in-person visits, a higher
percentage of patients with telemedicine visits gave higher
satisfaction ratings for access (62.5 percent versus 75.8
percent, respectively) and care provider concern (84.2 percent
versus 90.7 percent, respectively). Telemedicine visits
consistently outperformed in-person visits over time in terms
of access and care provider concern. (Patel 2023)
Summary
This list is not comprehensive; it simply represents a sample of
the thousands of studies and reports conducted on telehealth since
2020. The impact of telehealth on costs, quality, and access depends on
the condition, measure, and telehealth modality. The studies listed
here specifically focus on video visits and do not cover other
modalities, such as remote patient monitoring and telestroke. However,
in general: (1) telehealth expansion has not resulted in runaway
health-care spending or utilization; (2) telehealth does not compromise
the quality of care; (3) telehealth improves access to care.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
References
Beck, A., Buche, J., Page, C. Behavioral Health Provider Experiences
with Telehealth in Michigan During COVID-19. Institute for Healthcare
Policy and Innovation. Policy Brief.
https://ihpi.umich.edu/MItelehealth
Chen, J., Li, K.Y., Andino, J., Hill, C.E., Ng, S., Steppe, E.,
Ellimoottil, C. Predictors of Audio-Only Versus Video Telehealth Visits
During the COVID-19 Pandemic. J Gen Intern Med. 2022 Apr;37(5):1138-
1144.
Dixit, R.A., Ratwani, R.M., Bishop, J.A., Schulman, K., Sharp, C.,
Palakanis, K., Booker, E. The impact of expanded telehealth
availability on primary care utilization. NPJ Digit Med. 2022 Sep
9;5(1):141.
Ellimoottil et al. Analysis of Medicare FFS data; 2023.
Gerhart, J., Piff, A., Bartelt, K., Barkley, E. Fewer In-Person Follow-
Ups Associated with Telehealth Visits Than Office Visits. Epic
Research.
https://epicresearch.org/articles/fewer-in-person-follow-ups-
associated-with-telehealth-visits-than-office-visits. Accessed on
November 12, 2023.
Frost, M.C., Zhang, L., Kim, H.M., Lin, L.A. Use of and Retention on
Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use
Disorder During the COVID-19 Pandemic. JAMA Netw Open. 2022 Oct
3;5(10):e2236298.
Li, K.Y., Ng, S., Zhu, Z., McCullough, J.S., Kocher, K.E., Ellimoottil,
C. Association Between Primary Care Practice Telehealth Use and Acute
Care Visits for Ambulatory Care-Sensitive Conditions During COVID-19.
JAMA Netw Open. 2022 Mar 1;5(3):e225484.
Li, K.Y., Zhu, Z., Ng, S., Ellimoottil, C. Direct-To-Consumer
Telemedicine Visits For Acute Respiratory Infections Linked To More
Downstream Visits. Health Aff (Millwood). 2021 Apr;40(4):596-602.
Hatef, E., Wilson, R.F., Hannum, S.M., Zhang, A., Kharrazi, H., Weiner,
J.P., Davis, S.A., Robinson, K.A. Use of Telehealth During the COVID-19
Era. Systematic Review. (Prepared by the Johns Hopkins University
Evidence-based Practice Center under Contract No. 75Q80120D00003.) AHRQ
Publication No. 23-EHC005. Rockville, MD: Agency for Healthcare
Research and Quality; January 2023.
Medicare Payment Advisory Commission. June 2023. Report to the
Congress: Medicare and the health care delivery system. Washington, DC:
MedPAC.
Patel, K.B., Alishahi Tabriz, A., Turner, K., Gonzalez, B.D., Oswald,
L.B., Jim, H.S.L., Nguyen, O.T., Hong, Y.R., Aldawoodi, N., Cao, B.,
Wang, X., Rollison, D.E., Robinson, E.J., Naso, C., Spiess, P.E.
Telemedicine Adoption in an NCI-Designated Cancer Center During the
COVID-19 Pandemic: A Report on Patient Experience of Care. J Natl Compr
Canc Netw. 2023 May;21(5):496-502.e6.
Palzes, V.A., Chi, F.W., Metz, V.E., Sterling, S., Asyyed, A., Ridout
K.K., Campbell, C.I. Overall and Telehealth Addiction Treatment
Utilization by Age, Race, Ethnicity, and Socioeconomic Status in
California After COVID-19 Policy Changes. JAMA Health Forum. 2023 May
5;4(5):e231018.
______
Prepared Statement of Ateev Mehrotra, M.D., MPH, Professor of Health
Care Policy, Department of Health Care Policy, Harvard Medical School
Next Steps in Telehealth Payment and Regulatory Policy
Thank you, Chairman Cardin, Ranking Member Daines, and
distinguished members of the subcommittee; I am honored to have been
invited to testify before you on a topic of such critical importance to
Americans and their health.
My name is Dr. Ateev Mehrotra. I am a physician at the Beth Israel
Deaconess Medical Center and a professor at Harvard Medical School. My
research focuses on the impact of telehealth. Specifically, how does
telehealth impact quality, spending, and people's ability to access
care, particularly in rural communities? I have studied a wide range of
clinical applications of telehealth, including stroke, mental illness,
substance use disorders, contraception, and acute respiratory illness.
I do this research because I hope telehealth can help address the
common complaint I hear as a physician and what I am sure you hear from
your constituents: that people across this Nation often have difficulty
accessing timely care.
introduction
The rapid adoption of telehealth early in the pandemic was
dizzying, with telehealth visits accounting for 42 percent of Medicare
outpatient visits in April-May 2020.\1\ Clinical changes that I would
have expected to take a decade occurred within weeks. Most Federal
pandemic-era telehealth policies have remained temporary and have been
extended numerous times by Congress. Implicit or explicit in the
legislation authorizing these extensions is that more research is
needed to dictate permanent regulations. As I describe below, some of
that evidence is starting to emerge.
\1\ Gray, J., Tengu, D., and Mehrotra, A. 3 surprising trends in
seniors' telemedicine use during the pandemic. STAT News. Aug. 30,
2021. https://www.statnews.com/2021/08/30/three-surprising-trends-
seniors-telemedicine-use-pandemic/.
Some contemplated whether the unprecedented rates of telehealth use
during the COVID-19 pandemic were the beginning of a new normal--one
with telehealth as a core component of how patients receive care. The
result has been more of a modest change in most clinical areas than a
paradigm shift.\2\ The number of telehealth visits per month in the
United States continues to fall since its peak in April 2020 and today
represents roughly 5 percent of all outpatient visits in Medicare.
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\2\ One critical exception is treatment of mental illness where we
have seen more sustained use of telemedicine.
In surveys and interviews, patients and physicians have greatly
valued the availability of telehealth and want it to remain an option
in the future.\3\ However, both patients and physicians have questioned
the quality of care in a telehealth visit, specifically due to the
inability to conduct a full physical exam and key tests (e.g.,
electrocardiograms).\4\ Many patients prefer in-person visits.\5\
---------------------------------------------------------------------------
\3\ Mandated report: Telehealth in Medicare, Report to the
Congress: Medicare and the Health Care Delivery System, June 2023.
MedPAC, https://www.medpac.gov/wp-content/uploads/2023/06/
Jun23_Ch7_MedPAC_Report_To_Congress_SEC.pdf.
\4\ SteelFisher, G.K., McMurtry, C.L., Caporello, H., Lubell, K.M.,
Koonin, L.M., Neri, A.J., Ben-Porath, E.N., Mehrotra, A., McGowan, E.,
Espino, L.C. and Barnett, M.L., 2023. Video Telemedicine Experiences in
COVID-19 Were Positive, But Physicians and Patients Prefer In-Person
Care for the Future: Study examines patient and physician opinion of
telemedicine experiences during COVID-19. Health Affairs, 42(4), pp.
575-584.
\5\ Predmore, Z.S., Roth, E., Breslau, J., Fischer, S.H. and
Uscher-Pines, L., 2021. Assessment of patient preferences for
telehealth in post-COVID-19 pandemic health care. JAMA Network Open,
4(12), pp. e2136405-e2136405. Sousa, J., Smith, A., Richard, J.,
Rabinowitz, M., Raja, P., Mehrotra, A., Busch, A.B., Huskamp, H.A. and
Uscher-Pines, L., 2023. Choosing or Losing in Behavioral Health: A
Study of Patients' Experiences Selecting Telehealth Versus In-Person
Care: Study examines patient experiences selecting telehealth versus
in-person care for behavioral health services. Health Affairs, 42(9),
pp. 1275-1282.
My testimony will focus on the future of payment policy and
regulations for telehealth. I began by describing three key principles
that I believe should drive telehealth policy, and then I specifically
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discuss the following six issues related to payment and regulation:
1. Permanent expansion of telehealth coverage for all Medicare
beneficiaries.
2. Whether telehealth visits should be paid at the same rate
as in-person visits.
3. Role of audio-only telehealth visits.
4. In-person visit requirements.
5. Physician licensure in the context of out-of-State
telehealth visits.
6. Telehealth payment models.
key principles of telehealth policy
The first principle is that policymakers should formulate their
telehealth policy decisions through the lens of value. In the case of
telehealth, value is the dollars per improvement in care outcomes and
access. Improvements in access could decrease travel time, disruption
to lives, and the need for child care. Under the value framework, the
questions are: what are the high-value applications of telehealth? And
how can policies encourage higher-value applications of telehealth and
discourage lower-value applications of telehealth?
Value is dictated by the condition treated (for example, common
cold versus stroke) and the patient receiving care. Consider two
patients with depression who can participate in a telehealth visit. One
lives in rural Alaska with no access to local clinicians and
substantial transportation barriers. Telehealth could be the only way
he can access care and improve his condition. The second patient lives
in Anchorage, her depression is well controlled, she sees her
psychiatrist every month, and she is on the right medications. There is
minimal value in an additional telehealth visit every 2 weeks for her
depression.
Many of the policies that have been considered or implemented (for
example, targeted expansions of telehealth by condition and limitations
on which patients can receive telehealth) try to prioritize higher-
value applications of telehealth while continuing to restrict
applications with uncertain value. For example, implicit in Congress's
expansion of telehealth for rural communities is that rural residents
have more difficulty accessing care. Implicit in the expansion of
telehealth for mental illness treatment is that mental illness is
undertreated in the United States. The hope is that targeted expansions
result in substantial quality improvements at a reasonable cost.
It is important to acknowledge that all such policies are
inherently crude. There are patients in rural communities who are
getting all the care they need without telehealth, and there are plenty
of patients in urban areas who are not getting the care they need.
Fundamentally, using billing rules and regulations in the fee-for-
service system to determine when one form of telehealth is allowed and
another is not allowed is a daunting task--clinicians and patients will
quickly point out circumstances where the payment rules do not make
sense. The growth of telehealth has accelerated the need to shift to
other forms of payment.\6\ This is a topic I touch upon below.
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\6\ Adler-Milstein, J. and Mehrotra, A., 2021. Paying for digital
health care--problems with the fee-for-service system. New England
Journal of Medicine, 385(10), pp. 871-873.
The second principle is that we should try to avoid one-size-fits-
all telehealth policies--just as there can be no single coverage policy
for all prescription drugs. In the same way different drugs yield
different outcomes, telehealth's benefits will vary across clinical
conditions, different forms of telehealth, and different providers. For
example, telehealth for treating stroke could save lives, while
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telehealth visits for the common cold have little clinical benefit.
There are many different forms of telehealth. While much of the
focus of debate on telehealth policy is on video visits, the pandemic
has led to a surge in other forms of telehealth that have received less
attention, such as asynchronous visits (eVisits), consultations between
clinicians (eConsults), remote patient monitoring, and simple messages
from patients asking for advice. Across over 300 health systems that
use the Epic electronic health record, there has been a 57-percent
increase during the pandemic in the number of messages patients submit
daily via patient portals asking for medical advice.\7\ While I largely
focus on video visits, I will touch upon payment policy for other forms
of telehealth.
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\7\ Holmgren, A.J., Downing, N.L., Tang, M., Sharp, C., Longhurst,
C. and Huckman, R.S., 2022. Assessing the impact of the COVID-19
pandemic on clinician ambulatory electronic health record use. Journal
of the American Medical Informatics Association, 29(3), pp. 453-460.
Another critical distinction in telehealth policy is the type of
provider. While
telehealth-only providers may improve access for Americans and have
introduced many innovative models of care, they also raise new issues.
They have lower overhead costs than ``brick and mortar'' providers
because they do not have to pay for office space and equipment. Also,
due to the pressures of venture capital funding, they have been
pressured to grow as rapidly as possible. This pressure to grow rapidly
may have been one driver of a recent scandal where a direct-to-consumer
telehealth company was accused of overprescribing stimulant
medications.\8\ It is unclear whether telehealth-only providers should
be regulated and reimbursed differently.
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\8\ Startup Cerebral Soared on Easy Adderall Prescriptions. That
Was Its Undoing. Wall Street Journal. June 8, 2022.
The third principle is that we want to limit the administrative
burden. Administrative burden frustrates patients and clinicians and
drives up spending. Already, clinicians sometimes struggle to correctly
bill and document for telehealth visits.\9\
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\9\ Wilcock, Andrew D., et al. ``Legislation Increased Medicare
Telestroke Billing, but Underbilling and Erroneous Billing Remain
Common: Study examines Medicare telestroke billing.'' Health Affairs
41.3 (2022): 350-359.
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impact of telehealth on spending, quality, and access
Concern that telehealth will drive up health-care costs is a key
impediment to its permanent expansion. Consistent with others,
including the Congressional Budget Office,\10\ I have expressed concern
that greater telehealth use will increase spending. The concern is that
in some circumstances, telehealth is too convenient and may encourage
greater use of care such that telehealth visits may largely be additive
to the health-care system. In other words, telehealth's ability to make
care convenient and more accessible--the key to its enormous potential
to improve the health of many patients--may also be its Achilles' heel.
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\10\ Lori Housman, Zoe Williams, and Philip Ellis,
``Telemedicine,'' Congressional Budget Office, July 29, 2015, https://
www.cbo.gov/publication/50680.
After several years, evidence is beginning to emerge on the impact
of greater use of telehealth. In our work, we took advantage of
variations in uptake across large health systems to understand the
impact of telehealth use. For various reasons, including the type of
electronic health record, health system leadership, and local policy,
some health systems adopted telehealth to a greater degree than others.
We compared patients receiving care at health systems that used more
telehealth during the COVID-19 pandemic to those that relied more on
in-person services. The difference in telehealth use in 2020 was
substantial--patients assigned to the highest telemedicine adoption
health systems received 27 percent of their visits via telemedicine
compared to 10 percent in the lowest telemedicine adoption. Though
telemedicine use fell through December 2022, patients at high
telemedicine health systems continued to receive more telemedicine
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through the end of 2022.
In 2021-2, we found a relative increase of 2.2 percent in visits
per patient per year between patients in the highest and lowest
telehealth use health systems. Most of these visits (83 percent)
substituted for in-person visits. The relative increase in visits was
larger among lower-income, non-White patients. Patients receiving care
from higher telehealth health systems also had small improvements in
chronic disease medication adherence and decreased ED visits. However,
these changes accompanied a $248 (1.6-percent) increase in health-care
spending per capita.
Our results showing increases in visits, small increases in
spending, and modest improvements in quality are qualitatively
consistent with other recent work. An analysis for the Medicare Payment
Advisory Commission found that geographic areas with higher telehealth
uptake through 2021 had a 3 percent relative increase in total clinical
encounters and a spending increase of $165 per capita.\11\ A 2021 study
in Ontario found that greater physician telehealth uptake was
associated with small decreases in ED visits.\12\ Another analysis
focused on telehealth for mental illness found that greater telehealth
use was associated with more total visits (in-person plus telehealth)
without substantial improvement in quality metrics.\13\ Our results are
also consistent with Congressional Budget Office modeling that
telehealth expansions for mental illness will increase spending because
of projected increases in total visits.\14\
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\11\ Mandated report: Telehealth in Medicare, Report to the
Congress: Medicare and the Health Care Delivery System, June 2023.
MedPAC, https://www.medpac.gov/wp-content/uploads/2023/06/
Jun23_Ch7_MedPAC_Report_To_Congress_SEC.pdf.
\12\ Kiran, T., Green, M.E., Strauss, R., Wu, C.F., Daneshvarfard,
M., Kopp, A., Lapointe-Shaw, L., Latifovic, L., Frymire, E. and
Glazier, R.H., 2023. Virtual care and emergency department use during
the COVID-19 pandemic among patients of family physicians in Ontario,
Canada. JAMA Network Open, 6(4), pp. e239602-e239602.
\13\ Wilcock, Andrew D., et al. ``Use of Telemedicine and Quality
of Care Among Medicare Enrollees With Serious Mental Illness.'' JAMA
Health Forum. Vol. 4. No. 10. American Medical Association, 2023.
\14\ Hall, C., Housman, L., Osgood, H. CBO Cost Estimate H.R. 5201
[Internet]. Washington, DC; 2020. https://www.cbo.gov/system/files/
2020-12/hr5201.pdf.
Though we observe an increase in outpatient visit utilization, the
increases that we and others have documented are relatively small.
Several factors may explain this. Clinicians may have limited capacity
to provide additional visits. Alternatively, there may have been
limited demand from patients. As noted above, patients have worried
that the quality of telehealth visits is lower than in-person
visits.\15\
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\15\ SteelFisher, G.K., McMurtry, C.L., Caporello, H., Lubell,
K.M., Koonin, L.M., Neri, A.J., Ben-Porath, E.N., Mehrotra, A.,
McGowan, E., Espino, L.C. and Barnett, M.L., 2023. Video Telemedicine
Experiences in COVID-19 Were Positive, but Physicians and Patients
Prefer In-Person Care for the Future: Study examines patient and
physician opinion of telemedicine experiences during COVID-19. Health
Affairs, 42(4), pp. 575-584.
It is important to acknowledge the limitations of these studies. We
use data through 2022, when there were still ongoing waves of COVID-19
illness, which may have impacted health care seeking behavior. One must
be cautious in extrapolating results from the care patterns during the
pandemic to those we will observe after the pandemic. The effects of
telehealth on quality and spending could change as technology improves,
health systems optimize telehealth services or patient demand changes.
The results may not translate to virtual-only companies, and these
broad-based evaluations do not capture the quality outcomes specific to
a clinical area. Therefore, moving forward, it will be important to
continue monitoring telehealth's impact on quality and spending in
different clinical areas.
Policy Recommendation
Acknowledging these limitations, I recommend that Congress
permanently eliminate site-location requirements and allow video visits
for all conditions at any site to any Medicare beneficiary in the
United States. My recommendation tries to balance the principles I
described above. While telehealth does not reduce health-care spending,
the increase in spending is modest, and the research has highlighted
that greater telehealth can result in small improvements in access and
quality. Perhaps most importantly, patients and clinicians want
telehealth to remain an option, and policymakers will find it difficult
to ``take away'' telehealth. Limiting telehealth expansions to some
conditions or patients adds administrative burden (for example,
navigating different modifier codes). Finally, almost 4 years after the
pandemic's start, it is reasonable to signal to clinicians that
telehealth payments are here to stay so they can make investments in
telehealth with more certainty.
I would also permanently allow Federally Qualified Health Centers
and Rural Health Clinics clinicians to provide telehealth visits beyond
mental health visits as ``distant'' clinicians, enabling them to
provide telemedicine care to patients in their homes. These clinics
often treat patient populations with greater difficulties accessing
care; therefore, their telehealth visits will likely be of higher
value.
Invariably, areas will emerge where we observe overuse or low-value
telehealth use. But those areas could be addressed on a case-by-case
basis by Medicare. For example, Medicare could address concerns of
fraud or overuse by requiring in-person visits if a physician wants to
order specific high-cost tests.
Given the rapid pace of change in telehealth, I believe it is
critical to give Medicare as much flexibility as possible in adapting
telehealth policy. As noted above, I am both excited and concerned
about the emergence of virtual-only companies. To better track the care
they provide, Medicare should be able to require clinicians to report
if they have any corporate affiliations and Medicare should have the
ability to exclude specific companies they believe provide low-value
care.
payment parity
Payments for office visits in the Medicare system are based on the
time a physician or other clinician takes to provide care and the
overhead to support the space, staff, and equipment necessary to
provide that visit. For a common office visit (CPT 99213), the payment
is roughly half for physician time and half for these practice
expenses. While it does require some overhead, telehealth visits do not
require the same practice expenses as in-person visits. Physicians also
believe that telehealth visits cost less than in-person visits.\16\
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\16\ Mandated report: Telehealth in Medicare, Report to the
Congress: Medicare and the Health Care Delivery System, June 2023.
MedPAC, https://www.medpac.gov/wp-content/uploads/2023/06/
Jun23_Ch7_MedPAC_Report_To_Congress_SEC.pdf.
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Policy Recommendation
I recommend that telehealth visits be paid less than in-person
visits. Some clinicians have objected. They argue that their practice
expenses have remained the same because they provide both in-person and
telehealth visits and therefore must maintain the same staff and
resources. This argument does not convince me. I do not think Medicare
should cross-subsidize in-person visits with telehealth visits because
it will create distortions in the market. Paying the same amount for
telehealth visits will give virtual-only companies a competitive
advantage. It will also incentivize brick-and-mortar clinicians to give
up their practice. We find that roughly 5 percent of mental health
specialists have given up their physical office and gone ``virtual
only.''
The correct difference in payment between a telehealth visit and an
in-person visit is unclear. Currently, Medicare reimburses for a
telehealth visit 25 percent less than an in-person visit.\17\ While
this is a reasonable starting place, this difference may need to be
adjusted as Medicare receives more data on the practice expenses
necessary to provide telehealth visits.
---------------------------------------------------------------------------
\17\ Mandated report: Telehealth in Medicare, Report to the
Congress: Medicare and the Health Care Delivery System, June 2023.
MedPAC, https://www.medpac.gov/wp-content/uploads/2023/06/
Jun23_Ch7_MedPAC_Report_To_Congress_SEC.pdf.
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audio-only telehealth visits
Another area of debate is the role of audio-only visits. Though it
is unclear exactly what fraction of telehealth visits are audio-
only,\18\ it is clear that they are quite common. Audio-only visits may
be particularly important for disadvantaged communities and safety-net
clinics.\19\ In a study on digital access, we found the proportion of
patients with access to the necessary technology for a video visit was
lower among those with a high school education or less, were Black or
Hispanic, received Medicaid, or had a disability.\20\ Many policymakers
have mandated coverage of audio-only visits to ensure all people have
access to telehealth. For example, Arkansas, Florida, Kentucky,
Vermont, and Washington have all passed legislation ensuring access to
audio-only care for all residents or those with Medicaid.\21\ However,
there are also concerns from physicians and policymakers that audio-
only care may lead to inferior care. Though there is limited data on
the quality of audio-only telehealth visits, in a survey of clinicians
who treat substance use disorder, 70 percent perceived that their
patients received higher-quality care via video than audio-only
visits.\22\
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\18\ Hailu, R., Uscher-Pines, L., Ganguli, I., Huskamp, H.A. and
Mehrotra, A., 2022. Audio-only telemedicine visits: flaws in the
underlying data make it hard to assess their use and impact. Health
Affairs Forefront.
\19\ Uscher-Pines, L., Sousa, J., Jones, M., Whaley, C., Perrone,
C., McCullough, C. and Ober, A.J., 2021. Telehealth use among safety-
net organizations in California during the COVID-19 pandemic. JAMA,
325(11), pp. 1106-1107.
\20\ Roberts, E.T., Mehrotra, A. Assessment of Disparities in
Digital Access Among Medicare Beneficiaries and Implications for
Telemedicine. JAMA Intern Med. Oct 1 2020;180(10):1386-1389.
doi:10.1001/jamainternmed.2020.2666.
\21\ Michael Ollove, S. Telehealth may be here to stay. PBS News
Hour. 2021; Health, Streeter D. Audio-Only Telemedicine Law Changes:
Hospital Facility Fees Prohibited and Established Relationship
Requirement Modified. Washington State Hospital Association. 2022,
Bailey, V. Florida Senate Passes Bill Allowing Audio-Only Telehealth
Use. mHealth Intelligence. 2022; Policy News, Kannensohn, K.J. Arizona
Passes Broad Telehealth Law With Audio-Only Coverage. McGuireWoods.
2021.
\22\ Uscher-Pines, L., Riedel, L.E., Mehrotra, A., Rose, S., Busch,
A.B., Huskamp, H.A. Many Clinicians Implement Digital Equity Strategies
To Treat Opioid Use Disorder. Health Aff (Millwood). Feb
2023;42(2):182-186. doi:10.1377/hlthaff.2022.00803.
One assumption is that clinicians turn to audio-only visits due to
patient preference. However, growing evidence shows clinicians also
turn to audio-only visits due to provider preference. Many clinicians
do not offer video visits to all their patients, and they are less
likely to be offered to historically marginalized groups.\23\ There is
substantial variation in video telemedicine use among Federally
Qualified Health Centers. This difference appears to be driven by their
information technology platforms and what investments were made in
helping patients address barriers to obtaining video visits.\24\
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\23\ Ganguli, I., Orav, E.J., Hailu, R., Lii, J., Rosenthal, M.B.,
Ritchie, C.S. and Mehrotra, A., 2023. Patient Characteristics
Associated With Being Offered or Choosing Telephone vs Video Virtual
Visits Among Medicare Beneficiaries. JAMA Network Open, 6(3), pp.
e235242-e235242.
\24\ Uscher-Pines, L., Arora, N., Jones, M., Lee, A., Sousa, J.L.,
McCullough, C.M., Lee, S., Martineau, M., Predmore, Z., Whaley, C.M.
and Ober, A.J., 2022. Experiences of Health Centers in Implementing
Telehealth Visits for Underserved Patients During the COVID-19
Pandemic: Results from the Connected Care Accelerator Initiative. Rand
Health Quarterly, 9(4).
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Policy Recommendation
I recommend that Medicare pay for audio-only telehealth visits for
a time-limited period, such as 2 years. Given the lower practice
expenses, I believe an audio-only visit should be paid less than a
video visit. While I recognize telephone calls may increase access for
disadvantaged populations, I am concerned about a future with a two-
tiered system where the poor and disadvantaged receive phone calls, and
the wealthy have video visits. Though a phone call may be sufficient in
many cases, I worry that on average phone calls may not lead to the
same level of care. I also recommend Medicare require physicians
providing an audio-only visit to attest that they offered the patient a
video visit and that their clinic provides resources to patients who
face barriers to video visits. I hope limiting payment for a short
period and requiring this attestation will spur the necessary
investments in support at clinics so that all Americans can receive a
video visit. It will also create an opportunity for more research on
what impact audio-only visits have on quality, spending, and access.
in-person visits before a telemental health visit
At the end of 2020, Congress permanently expanded coverage of
telemental health in Medicare but required that an individual have an
in-person visit within 6 months before the first telemental health
visit. Many mental health clinicians expressed concerns that there was
no evidence of clinical benefit for this requirement, and it would
create an unnecessary barrier to care. In December 2022, Congress
passed legislation delaying the in-person requirement until January
2025.
To better understand what impact this rule may have on care in the
future, we examined the care of Medicare fee-for-service beneficiaries.
Of the more than 800,000 first telemental health visits in 2022, only
19 percent were preceded by an in-person visit with that clinician. Our
results highlight that such a new requirement would require a
substantial change in current practice. It could also imply that
clinicians do not perceive in-person visits within 6 months as
clinically necessary.
Policy Recommendation
I believe that Congress should remove the requirement for in-person
visits requirements before mental health visits. While removing this
requirement will likely increase spending on mental health, requiring
in-person visits will decrease the ability of telehealth to expand
access to mental health services for patients who live far from any
mental health clinician and, therefore cannot have in-person care.
physician licensure and the role of exceptions
The COVID-19 pandemic prompted Federal and State Governments to
relax licensure requirements temporarily to facilitate out-of-State
physicians' care. During the early-pandemic period (through mid-2021),
there was substantial use of out-of-State telehealth.\25\ Among all
Medicare beneficiaries with a telemedicine visit, 5 percent had an out-
of-State telemedicine visit. In most cases, this was a continuation of
an established relationship. Out-of-State telemedicine use was greatest
for some conditions, such as cancer, among people who lived near a
State border and in more rural States such as Montana and South Dakota.
Most of these temporary regulations have now expired.
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\25\ Andino, J.J., Zhu, Z., Surapaneni, M., Dunn, R.L. and
Ellimoottil, C., 2022. Interstate Telehealth Use By Medicare
Beneficiaries Before and After COVID-19 Licensure Waivers, 2017-20:
Study examines interstate telehealth use by Medicare beneficiaries
before and after COVID-19 led to relaxed licensure rules. Health
Affairs, 41(6), pp. 838-845. Mehrotra, A., Huskamp, H.A., Nimgaonkar,
A., Chaiyachati, K.H., Bressman, E. and Richman, B., 2022, September.
Receipt of out-of-state telemedicine visits among medicare
beneficiaries during the COVID-19 pandemic. In JAMA Health Forum (Vol.
3, No. 9, pp. e223013-e223013). American Medical Association.
This return to pre-pandemic policy is not limited to video visits.
Follow-up phone calls are also victims of this return to pre-pandemic
licensure practice. Some lawyers have interpreted that a follow-up
phone call constitutes the ``practice of medicine'' and must be limited
to patients in a State where the physician is licensed. For example,
the governing code in Texas defines practicing medicine as the
``diagnosis, treatment, or offer to treat a mental or physical disease
or disorder or a physical deformity or injury by any system or method''
and notes that any ``person who is physically located in another
jurisdiction but who, through the use of any medium, including an
electronic medium, performs an act that is part of a patient care
service initiated in this State . . . that would affect the diagnosis
or treatment of the patient, is considered to be engaged in the
practice of medicine.''\26\ Texas is not unique; similar definitions
and rules exist in other States. Such rules can create issues for a
patient seeking clinical advice from a physician in their home State
while traveling to another State.
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\26\ Occupations Code Chapter 151. General Provisions. https://
statutes.capitol.texas.gov/Docs/OC/htm/OC.151.htm.
These geographic limitations of telehealth visits have created
substantial frustration. Patients wonder why driving across a State
border results in better care. For many video telehealth visits,
patients sit in cars or coffee shops on smartphones, searching for good
WiFi and sharing tips about the best parking lots just across the State
border.\27\ And many patients simply stopped following up with their
out-of-State physicians.\28\
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\27\ Shachar, C., Richman, B.D. and Mehrotra, A., 2023. Providing
Responsible Health Care for Out-of-State Patients. JAMA.
\28\ Bressman, E., et al., Expiration of State Licensure Waivers
and Out-of-State Telemedicine Relationships. JAMA Network Open, 2023,
In press.
Unfortunately, reforms such as the Interstate Medical Licensure
Compact, a process for making it easier for physicians to get a full
license in multiple States, or the use of special telehealth licenses
have had limited benefits. Expanding the use of licensure exceptions
would be more helpful.\29\ Many States have already incorporated
exceptions to their licensure requirements. For example, Arizona allows
a physician licensed in another State to provide telehealth to a
patient in Arizona ``[t]o provide after-care specifically related to a
medical procedure that was delivered to a person in another State.''
Other key groups, such as the American Medical Association, support the
need for greater use of exceptions for out-of-state telemedicine
follow-up care. The Federation of State Medical Boards (FSMB) believes
there is a need for exceptions that ``permit the practice of medicine
across State lines without the need for licensure in the jurisdictions
where the patient is located. These exceptions to licensure are only
permissible for established medical problems or ongoing workups and
care plans.''\30\
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\29\ Consensus Statement for Telehealth Licensure Reforms. Petrie-
Flom Center for Health Law Policy, Biotechnology, and Bioethics.
https://chlpi.org/wp-content/uploads/2023/11/Consensus-statement-
Circulation-AMH_FINAL.pdf.
\30\ Federation of State Medical Boards, The Appropriate Use of
Telemedicine Technologies in the Practice of Medicine. April 2022.
https://www.fsmb.org/siteassets/advocacy/policies/fsmb-workgroup-on-
telemedicineapril-2022-final.pdf.
Using these exceptions is relatively simple for a physician. A
physician only needs to be aware of the limitations of exceptions and
that one cannot initiate a physician-patient relationship using an
exception. From a patient perspective, such exceptions would allow most
patients to use telehealth when needed. A student who is away for
college can still see their psychiatrist in their home State. Patients
traveling for work can keep in touch with their primary care physician
regardless of where they are.
Policy Recommendation
I recommend Congress pass legislation implementing a narrow
exception to State licensure allowing any physician to provide
telehealth across State lines if they have an established prior
relationship with that patient and are licensed in good standing in
their home State. The advantage of Federal legislation is that it
creates a clear set of rules nationwide. While many States have
implemented similar exceptions, the language is not always consistent,
and physicians have to carefully track the specific rules in the State
where their patient is currently located. Creating this type of narrow
exceptions for licensure is consistent with prior Federal licensure
legislation, such as the Sports Medicine Licensure Clarity Act \31\ and
the VA MISSION Act.\32\
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\31\ Lennon, R.P., Day, P.G., Marfin, E.C., Onks, C.A., and Silvis,
M.L., 2022. A general framework for exploring ethical and legal issues
in sports medicine. The Journal of the American Board of Family
Medicine, 35(6), pp. 1230-1238.
\32\ Crowley, R., Atiq, O., Hilden, D., Cooney, T.G., and Health
and Public Policy Committee of the American College of Physicians,
2021. Health Care for Our Nation's Veterans: A Policy Paper From the
American College of Physicians. Annals of Internal Medicine, 174(11),
pp. 1600-1602.
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paying for other forms of telehealth
As noted above, telehealth is not limited to video and audio-only
visits. We are seeing rapid growth in other telehealth applications,
such as remote patient monitoring.\33\ In some cases, Medicare is
paying for such care using monthly bundled payments instead of fee-for-
service payments. The bundled payments include payments for data
transfer costs and all communication between clinicians and patients in
the month.
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\33\ Tang, M., Nakamoto, C.H., Stern, A.D. and Mehrotra, A., 2022.
Trends in remote patient monitoring use in traditional Medicare. JAMA
Internal Medicine, 182(9), pp. 1005-1006.
Similar payment innovation is needed for other forms of telehealth,
such as portal messages.\34\ The number of portal messages has surged
during the pandemic, and clinicians, particularly primary care
physicians, are frustrated because they spend substantial time at night
answering these messages largely without reimbursement.\35\ The fee-
for-service system is poorly suited for frequent but short
interactions, such as short phone calls or portal messages. When the
units become smaller and smaller (e.g., it may take a clinician only 2
minutes to respond to a portal message), the estimated $20 of
administrative costs required to submit a bill for a single patient
encounter may not be worth it.
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\34\ Adler-Milstein, J. and Mehrotra, A., 2021. Paying for digital
health care--problems with the fee-for-service system. New England
Journal of Medicine, 385(10), pp. 871-873.
\35\ As More Patients Email Doctors, Health Systems Start Charging
Fees. KFF Health News. September 14, 2023. https://kffhealthnews.org/
news/article/email-doctor-visits-new-fees-copays/.
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Policy Recommendation
I encourage giving Medicare as much flexibility in creating payment
models that use partial capitation or bundled payments to pay for
telehealth applications such as portal messages. Such alternative
payment models give clinicians the flexibility to use the full range of
telemedicine tools (portal messages, video visits, eVisits, phone
calls, eConsults, telemonitoring) best suited for an individual patient
and clinical scenario and avoid the administrative burden of billing
for each encounter.
summary of policy recommendations
To summarize, my policy recommendations are:
Permanently eliminate site-location requirements and allow
for video visits for all conditions for all Medicare
beneficiaries.
Pay for telehealth visits at a lower rate than in-person
visits, avoiding telehealth parity.
Pay for audio-only telehealth visits for only a time-limited
period and require attestation from the clinician that they
offered the patient a video visit.
Remove in-person visit requirements before mental health
visits.
Introduce selective exceptions to State licensure that allow
patients to get care from any clinician with whom they have an
established relationship.
Encourage innovation in payment models for telehealth that
use bundled payments of partial capitation.
I acknowledge that the coverage decisions and payment choices I
recommend are not perfect. They will deter some effective forms of
telehealth and may add some administrative burden. Also, telehealth use
is rapidly changing, and policy must adapt accordingly. However, I
believe they represent the best way to encourage high-value
applications of telehealth and encourage a necessary transformation of
our health-care system.
Again, I thank Chairman Cardin, Ranking Member Daines, and members
of the subcommittee for allowing me to appear before you today to
discuss this critical topic in health care.
______
Prepared Statement of Nicki Perisho, BSN, R.N., Principal Investigator
and Program Director, Northwest Regional Telehealth Resource Center
Chairman Senator Cardin, Ranking Member Senator Daines, and members
of the Senate Committee on Finance, Subcommittee on Health Care, thank
you for the opportunity to testify at today's hearing: ``Ensuring
Medicare Beneficiary Access: A Path to Telehealth.'' The views I am
sharing today are my personal opinions and are not the views of the
Health Resource Services Administration (HRSA), my employer the
University of Utah, or the Northwest Regional Telehealth Resource
Center (NRTRC).
I believe it is crucial to emphasize the significance importance
telehealth services are for Medicare beneficiaries. It is my belief
that leniencies around eliminating the geographical restrictions for
originating and distant site telehealth providers, audio-only
telehealth visits, and allowable provider types and payment parity have
had and why they should remain permanent in Medicare coverage.
I am pleased that the subcommittee is exploring telehealth that
delivers the right care, in the right place, at the right time to
patients in ways that work for them, while providing appropriate
payment to the practitioners and facilities providing those health-care
services. I am honored and humbled to testify alongside this seasoned
panel of telehealth experts and want to note that in the absence of a
patient witness, I will do my best to highlight the most important part
of the equation, the benefits of telehealth for the patient.
I'd like to start with just a few facts about Montana, the fourth
largest State by area, the eighth least populous State, and the third
least densely populated State in the country.\1\, \2\ Low
population density results in limited access to health care, most
largely seen in specialty care, where providers are sparse. The
population density by State underestimates the extremely rural nature
of the Northwest region and Montana specifically.
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\1\ https://www2.census.gov/geo/pdfs/reference/glossry2.pdf.
\2\ https://www.census.gov/.
The Native American/Alaskan Native populations living in the
Northwest region make up a higher percentage than the total population
in the rest of the Nation, with 6.3 percent of the Native American and
Alaska Native population residing in Montana per the 2019 ACS 1-Year
Estimates.\3\
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\3\ https://www.census.gov/programs-surveys/acs/technical-
documentation/table-and-geography-changes/2019/1-year.html.
------------------------------------------------------------------------
Montana
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Total Population 1,068,778
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Area (Sq. Mi.) 145,508
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Rank of State by area 4th
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Tribal lands (Sq. Mi.) 145,555
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Number of Tribes 7
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Population Density 7.35
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Rural Percent of Population 44%
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MUA/MUPs 51
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HPSA/Primary Care 138
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HPSA/Dental 123
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HPSA/Mental Health 110
------------------------------------------------------------------------
Historically, Americans residing in rural and frontier areas have
faced disproportional challenges compared to their urban counterparts
regarding access to clinical and behavioral health-care services. This
disparity increased during the COVID-19 pandemic and stems from
longstanding social inequities and systemic health conditions rural
populations incur. Data indicates that rural communities experience
higher blood pressure, obesity, diabetes, and higher incidence of
tobacco consumption, putting individuals at higher risk of negative
health outcomes from lack of access to quality, continuous disease
management and mental health services. With the combination of
increased comorbidities, decreased access to health care, and the
decreased probability of health insurance coverage, rural community
members are more likely to have a negative health outcome.\4\ Research
also reveals that rural and frontier residents are more likely than
their urban counterparts to experience a higher incidence of suicide,
unintentional injuries, and premature death. These residents also tend
to be uninsured or underinsured, have lower incomes or live in poverty,
lack social support, and are without a regular source of health care.
Results from the CDC ``Mortality in the United States'' report found
that Montana, Alaska, and Wyoming have the highest suicide rates in the
Nation.\5\
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\4\ https://www.cdc.gov/coronavirus/2019-ncov/need-extra-
precautions/other-at-risk-populations/rural-communities.html.
\5\ https://www.cdc.gov/nchs/pressroom/sosmap/suicide-mortality/
suicide.htm.
I'd like to share why I am so passionate about telehealth.
Following an internship at Craig Hospital, a neurorehabilitation and
research hospital in Denver, CO, I began working as a critical care
nurse in northwestern Montana; the patients I cared for included post-
stroke patients. In 2010, the regional Montana hospital I was working
for was awarded a Distance Learning and Telemedicine (DLT) grant
through the United States Department of Agriculture (USDA). I was asked
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to lead the innovative telestroke program.
The telestroke program started by providing audio and video
equipment to three critical access hospitals (CAHs) in northwest
Montana, along with 24/7 neurologist coverage for patients suspected of
suffering a stroke. Montana has 49 CAHs, and the majority of them are
staffed with nurse practitioners, physician assistants, or family
practice providers.\6\ Rural patients who are suspected of suffering an
acute ischemic stroke, an embolism, or a clot that stops the blood
supply to brain tissue, might be candidates for tissue Plasminogen
Activator (tPA) \7\ which should be administered within 4\1/2\ hours of
the onset of stroke symptoms. This is where the telestroke program
becomes so valuable. A neurologist can assess the patient over video
alongside a local practitioner and can decide whether or not to
administer tPA. At that point, the patient is transferred via flight to
a qualified stroke center in a larger city.
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\6\ https://mtpin.org/member-resources-facilities/montana-cahs/.
\7\ https://www.ninds.nih.gov/about-ninds/impact/ninds-
contributions-approved-therapies/tissue-plasminogen-activator-acute-
ischemic-stroke-alteplase-activaser.
As part of the telestroke program, a vascular neurologist (who
happened to have grown up in Montana and was at that time, the only
vascular neurologist in the State) and the stroke nurse (me) would
travel to the remote CAHs and provide education on the administration
and monitoring of tPA. We formed a relationship and trust between the
clinicians at the rural site and our telestroke team. During my time
with this program, it grew to 13 CAHs in Montana and to offer
specialties such as teleNeonatology, and telepediatrics. We also
created originating sites in rural communities for patients to go to
have a telehealth visit with their specialist in Kalispell. These types
of visits allowed a patient to stay in their community, not travel long
distances in in-clement weather, over mountain passes, alleviate risks
of collisions with wildlife, preventing the removal of students from
school, allowing parents to avoid taking time off from work.
Monetarily, this allowed families to save money on gas, lodging, and
food. The telestroke program is still in operation today, and the
neurologists authorized their 100th dose of tPA via telehealth this
past summer, potentially saving the lives of 100 patients. To note,
those patients, most likely will not need long-term care or therapies,
providing cost savings to the patient and the health-care system. I can
honestly say this was made possible by access to telehealth, when this
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program started, not one of the CAHs had administered tPA.
Due to the success of this program, the hospital created a
``Virtual Health Department,'' and I served as the virtual health
manager, supporting the growth of telehealth in northwest Montana. I
saw firsthand the benefits of telehealth. For instance, one cardiac
specialist shared gratitude after ``seeing'' a congestive heart failure
patient via telehealth and having the opportunity to look into the
patient's kitchen where he recognized that the patient's diet was
contributing to repeated trips to the ICU.
There have been frustrations. The city of Great Falls, population
60,400, did not have a nephrologist for patients with kidney diseases,
but because the city was deemed urban, patients were not able to go to
their local clinic as an originating spot to connect with a
nephrologist via telehealth. So, patients had to drive at least 90
miles to Helena to see a nephrologist.
In my current role at the NRTRC, I provide technical assistance to
practitioners wanting to implement, improve, or sustain telehealth
services. I provide telehealth education to medical and nursing
students. Based on my experiences, the four key areas I would like to
see be made permanent are:
1. Eliminating the geographical requirements for originating
site.
2. Preserving audio-only telehealth visits.
3. Expanding provider types for telehealth services.
4. Ensuring payment parity.
1. eliminating the geographical requirements for originating site
The origination site is defined as the location where a patient is
located when receiving health-care services by telehealth.\8\ Before
the pandemic, Medicare would reimburse for a telehealth visit if the
patient was at an address that did not fall in a metropolitan
statistical area; or, if the address was located in a metropolitan
statistical area, the address must be in a rural area and be in a
primary care or mental health geographic health professional shortage
area (HPSA). In 2020, the Federal administration removed these
restrictions, allowing patients to receive the care they needed, no
matter where they were located, when they needed it, and health-care
practitioners and facilities received payment equal to that of an in-
person visit.
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\8\ https://www.cms.gov/files/document/mln901705-telehealth-
services.pdf.
It would be a disservice to limit the originating site to a
patient's home or a clinical location. Locations such as public
libraries, community centers, fire stations, and even a patient's
parked vehicle in a place where they can access the Internet have
provided disadvantaged populations access to practitioners via
telehealth. By adhering to the geographic limitations, we are
contributing to the digital divide and health inequities. Many patients
living in urban areas benefit from telehealth as well. Many caregivers
don't have the ability to take their patients to an in-person doctor
visit, which might delay preventive care or access to mental health
services. Take the case of the wife of a man with frontotemporal
dementia (FTD) who cannot attend in-person appointments because his
particular manifestation of FTD does not allow him to be cared for by
someone else, and his behavior is too disruptive in a waiting room. The
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man's wife commented, ``Telehealth is literally a lifesaver for me.''
My colleagues and I have been working to develop a resource that
identifies Telehealth Access Points (TAPs, https://
findtelehealth.nrtrc.org/map), which are dedicated public spaces where
patients can access telehealth appointments. These spaces have a
private space for a telehealth visit, an adequate Internet connection,
along with a device with video, speaker, and microphone capabilities.
It is imperative to ensure that all patients have access to telehealth,
including those who may not have a private space or have limited
broadband accessat home.
2. preserving audio-only telehealth visits
Telehealth was a vital tool during the COVID-19 pandemic, ensuring
continuity of care, reducing health-care disparities, and enhancing
overall patient outcomes. Medicare's population of adults over age 60
account for 25 percent of physician office visits in the United States,
and often have multiple morbidities and disabilities. Thirteen million
older adults may have trouble accessing telemedical services that
requires both audio and video; a disproportionate number of those are
already disadvantaged in terms of accessing health care. Telephone
visits may improve access for the estimated 6.3 million older adults
who are inexperienced with technology or have visual impairments.\9\
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\9\ https://jamanetwork.com/journals/jamainternalmedicine/
fullarticle/2768772.
Audio-only telehealth is important to reduce barriers to Medicare
beneficiaries' access to care because it does not require proficiency
in using a smart device, having a webcam, or broadband connection.
There are certain populations that are not quite comfortable with using
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the Internet and video technology.
Broadband is not yet ubiquitous and can be expensive in rural
areas. Medicare rules should preserve an audio-only option for those
patients who don't have other means to seek medical services. A health-
care provider can provide qualified advice whether seeing the patient
in person, via video, or listening over the phone. It is necessary for
audio-only to be an option for those individuals who don't have
connectivity or any other way to seek medical services. If audio-only
telehealth is not made permanent, it is possible that certain
individuals might not be able to access these services.
According to a study published in the American Journal of Medical
Services, audio-only telehealth services provided similar benefits and
were not inferior to video-based virtual visits. Many study
participants shared that they would recommend an audio-only telehealth
visit to others and that their medical concerns were addressed
appropriately. Audio-only telehealth services promote health equity for
people who are economically disadvantaged, live in rural areas, are
racial or ethnic minorities, lack access to reliable broadband or
Internet access, or do not have access to devices with video
capabilities.\10\
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\10\ https://pubmed.ncbi.nlm.nih.gov/35793732/.
I recommend that the same allowances for audio-only that are made
for mental health visits are extended to clinical visits with provider
discretion on whether an in-person, audio and video communication or
audio-only communication is the best option for the health issue(s) and
the patient. As a reminder, those allowances are when beneficiaries are
not capable of, or do not consent to, the use of devices that permit a
two-way, audio-video interaction for the purposes of diagnosis,
evaluation of treatment of a mental health disorder.
3. expanding provider types for telehealth services
Federally Qualified Health Centers (FQCHs) provide primary care,
behavioral health services, dental, pharmacy, and a myriad of
wraparound services to underserved communities. The use of telehealth
during COVID was the first time that FQHCs were able to consistently
bill for services that they provided using telehealth for Medicare
beneficiaries. The conversation around telehealth expansion has long
centered around increasing access for patients, which FQHCs were able
to do through the COVID waivers. It's important that these COVID-driven
changes be made permanent, and that we also continue to adopt virtual
health technologies to assist with provider recruitment and retention
and finding ways to optimize staffing and workflows. For years FQHCs in
many States have been able to provide telehealth services for Medicaid
beneficiaries, making the more stringent requirements for Medicare
patients and reimbursement a source of health inequity.
Speech language pathologists, physical therapists, and occupational
therapists were able to provide telehealth services during COVID and be
reimbursed, demonstrating that those services could be provided safely
and effectively and that a large amount of Medicare patients needed to
use those services. To not have these services available could
potentially hinder a patient's recovery from health-care episodes, such
as stroke or post-orthopedic surgery or a pediatric patient born
prematurely. During my time at the hospital, we would discharge
pediatric patients after their neonatal intensive care with a
prescription for speech therapy, even though there were no speech
language pathologists within a 200-mile range.
4. payment parity
Providers who use their expertise and cognitive skills can attest
that they do not give a lower quality of service for patients that they
see via telehealth over those whom they see in-person, and this should
be reflected in reimbursement so telehealth is not disincentivized. To
note, the CMS Final Rule for CY 2024 Fee Schedule recognized that there
are still practice expenses providers and clinics incur when the
practitioner is in their home and have agreed to pay the non-facility
rate, which is higher than the facility rate. Practitioners are
expected to bill for certain things and if the service can meet the
definition of the code they are billing for, they should be reimbursed
the same amount regardless of whether or not the visit was in-person or
via telehealth.
A common barrier to the adoption of telehealth has been State-
specific laws and regulations governing reimbursement and professional
licensing requirements. When the administration declared a Public
Health Emergency (PHE) on March 13, 2020, and put waivers in place to
remove regulations around telehealth, patients were seen virtually,
keeping not only immunocompromised patients safe, but practitioners
safe, and were paid for these services. The Office of Inspector General
is monitoring potential fraud through use of telehealth (https://
oig.hhs.gov/reports-and-publications/featured-topics/telehealth/), and
there have not been any announcements thereof.
It is important to acknowledge that delivery of telehealth includes
myriad regulatory requirements, preferences, and challenges: and
coordination of allowable services per Medicare, State Medicaid
agencies, and other insurers, providers, locations, modalities,
billing, payers, reimbursement, technology, provider preference,
patient preference, to name a few. Now is the time to seize the
opportunity to streamline and improve telehealth service delivery for
everyone involved. The Office of Inspector General performed an audit
of 440,003 Montana Medicaid telehealth paid claim lines totaling $43.2
million from March 1st through December 31, 2020, analyzing the
procedure codes paid as telehealth and identifying which were allowable
for billing as telehealth. The audit found that 99.9 percent of the
lines reviewed were compliant with Federal and State requirements, and
Medicaid providers generally complied with Federal and State
requirements when claiming Medicaid reimbursement for telehealth
services during that period of the COVID-19 pandemic.\11\
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\11\ https://oig.hhs.gov/oas/reports/region7/
72103250.asp#::text=What%20OIG%20Found,
with%20Federal%20and%20State%20requirements.
In closing, telehealth plays a critical role in improving access to
timely and regular health services with highly qualified health-care
providers, especially for patients with challenges that affect access
and care coordination. By addressing the outlined recommendations,
Medicare beneficiaries will have consistent access to telehealth
services, promoting their overall health and well-being. Making the
telehealth leniencies discussed earlier a permanent fixture in Medicare
coverage is a significant step toward improving the lives of American
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citizens.
Thank you for your attention to this critical matter. I appreciate
the committee's dedication to enhancing health-care access for all
Americans, and I am hopeful that you and your colleagues will continue
to champion the cause of telehealth for Medicare beneficiaries.
______
Prepared Statement of Eric Wallace, M.D., FASN, Professor of Medicine,
UAB EMedicine; Medical Director, Co-Director of Home Dialysis, and
Director of the Rare Genetic Kidney Disease Clinic, Division of
Nephrology, Department of Medicine, University of Alabama
The Importance of Permanency of Telehealth Payment Coverage
Chairman Cardin, Ranking Member Daines, and distinguished members
of the Senate Finance Committee, thank you for the opportunity to
testify on behalf of the University of Alabama at Birmingham and the
American Medical Group Association. I am a professor of medicine in the
Division of Nephrology at UAB, and I am the medical director of the UAB
Health System telehealth program.
My role in telehealth started in 2013 when I recognized that one of
my elderly dialysis patients was driving 2 hours twice monthly to get
her dialysis care in Birmingham, AL. Furthermore, many of my patients
with rare diseases, primarily with Fabry disease, an inherited disease
which causes patients to suffer from severe pain, kidney failure,
stroke, and heart failure, were also driving hours to see me. Their
commutes and time spent in the waiting room were part of their disease
burden. I believed that my patients' lives could be made just a little
better if we could deliver the same quality care remotely. Furthermore,
for every patient that could make the drive and wait for me, were there
more patients that couldn't? What if we could reach everyone?
UAB is home to UAB Hospital, the 8th largest hospital in the
country, and performs over 1.7 million outpatient patient visits
yearly. It is a world-class institution and ranks 11th in NIH research
dollars awarded amongst public institutions. I am proud to call UAB not
only my employer but also my home. But how can you have a world-class
health-care institution in a State which ranks 46th in health-care
outcomes? What if we could remove even one barrier, such as geography,
to improve access to care?
So UAB, in collaboration with the Alabama Department of Public
Health, worked for 2 years and developed a way through telehealth for
me to see my dialysis and rare disease patients in a number of county
health departments across the State. In 2015, we did the first fully
comprehensive telehealth visit on a peritoneal dialysis patient.
There was a critical need for telehealth starting in 2020.
In March 2020, the President issued an emergency declaration for
all States, given the magnitude of the COVID-19 public health
emergency. UAB had already begun positioning ourselves for a rapid
transition to telehealth delivery of care. Because of the groundwork
laid years prior for Alabama patients to receive care over telehealth,
by April of 2020, UAB transitioned over 74 percent of our outpatient
clinic visits to telehealth. This allowed us to protect providers and
our patients from the COVID-19 virus in the only way we knew how
against an unknown pathogen at the time.
Furthermore, we watched telehealth transform rural hospitals. Prior
to COVID-19, UAB was providing telehealth inpatient care, including
telecritical care, telestroke, and telenephrology. When we started
delivering telehealth services to Whitfield Regional Medical Center in
Demopolis, AL, the average census of the hospital was around 20. In
2018, we started a telestroke, telecritical care, and telenephrology
program at Whitfield, and the census started increasing; the average
census is around 50 today. This is a significant benefit to the patient
and their families. Equally important, keeping the care in the
community helps our important rural health partners keep their doors
open.
In many cases, telehealth provides better care than the previous in
person alternative. Previously, if a dialysis patient arrived at
Demopolis with life-threatening high potassium, they were given a
medicine to remove the potassium through the stool. The patient would
then be put in an ambulance and transported to the nearest dialysis-
ready hospital, which would take at least 90 minutes. The ambulance had
to wait at the hospital while the patient waited on a bed, and finally,
around 8 to 12 hours later, the patient would be dialyzed. It was the
best we could do at the time. But this was a disservice to the patient.
An ambulance is used each time a patient is transferred to a larger
center from Demopolis. Marengo County, AL, only has 3 ambulances, so if
2 patients were being transferred due to a lack of local services, that
leaves only one ambulance to cover the whole county. With telehealth,
we are able to do a nephrology consult on the patient in Demopolis; the
rural hospital keeps the patient, and we are able to start dialysis
within 1 hour of the patient's arrival, thus saving a transfer and time
needed to treat the high potassium. Finally, UAB Hospital now has an
open bed that can accept even sicker patients.
During COVID-19, there were times when Vanderbilt, Emory, Ochsner,
and UAB were all full and could take no additional patients. Patients
with COVID-19 needed high-risk ventilation and, at times, needed
dialysis. I would be notified of these patients who otherwise would be
left to die in a facility with no way to care for them. I notified one
rural hospital without telehealth to transport their critically ill
patient to one of our rural sites that had access to telenephrology and
telecritical care. For the first time ever, patients were life-flighted
into rural Demopolis, AL, which now had the resources to care for them.
This demonstrates that telehealth has the potential to transform a
rural hospital bed from available but unusable to available and useful.
This is one of many examples of how telehealth is transforming care
across the country.
The primary regulatory changes on both the Federal and State level
that allowed for this complete and successful pivot to telehealth was:
1. The elimination of the geographic limitation;
2. The elimination of the originating site requirement;
3. The universal adoption of both private and public payers in
parity for telehealth visits; and
4. And the allowance of audio-only visits and pay parity.
Unfortunately, these regulatory ``flexibilities'' are not
permanent. They have been extended multiple times, with the current
expiration being the end of 2024. At the end of the COVID-19 public
health emergency, health-care providers that had successfully pivoted
to telehealth, which was not an easy transition for most, were left
with a seemingly endless barrage of new regulations regarding
licensure, variations between private and public insurers, regulations
in the prescribing of controlled substances, etc. Furthermore, the
possibility that none of the previous ``flexibilities'' would be
permanent added to provider frustration. We had been to war battling
COVID-19 armed with telehealth only to find we were now battling new
regulations. All of these regulatory hurdles increased to pre-pandemic
levels. They left many providers confused and frustrated, finding it
easier to give up on telehealth rather than to face an impossible
onslaught of regulations. As a result, the utilization of telehealth
began to decrease. But just as there was a need before COVID-19 for
telehealth, there is a need for telehealth now, and there will be a
need in the future. Incorporating strategies, including telehealth, is
the only way we will be able to organize our health care into
meaningful systems to deliver equitable care across our vast geographic
area in the United States.
As we look to the future, how will telehealth play a major role in
the success of any health care delivery system?
1. Telehealth is vital to the survival of rural health care--
My father is now a retired physician. When he started his
practice, it was not uncommon to be on call 7 days in a row
every month, and that was if you were lucky enough to have 3
other providers to partner with. This type of call schedule is
still common in rural areas. We are not training providers to
be on call in this manner, making recruiting providers to rural
practice difficult. Furthermore, the idea of practicing in a
rural area without access to subspecialist help can be enough
to decrease interest in establishing a practice in a rural
area. The average age of providers in rural areas everywhere is
increasing. Telehealth can help by providing call coverage and
access to subspecialty support to rural providers, thus
improving recruitment of primary care to these areas.
2. Telehealth will play an ever-growing role in value-based
care--The applicability of telehealth strategies, including
home-based telehealth visits and remote patient monitoring, has
been proven specifically in high-risk patients. As the
utilization of telehealth declines in the face of regulatory
struggles, we may lose some of the momentum needed to truly
realize the benefit that can be seen in value-based care
approaches.
3. Telehealth will continue to allow for the delivery of
inpatient subspecialty services to urban and rural settings--
The inpatient delivery of subspecialty care is vital for both
small urban and rural areas. These approaches allow for the
distribution of a subspecialty workforce largely centered in
large urban areas.
4. Telehealth can alleviate nursing and provider staffing
shortages by leveraging urban or national-based workforces.
Telehealth has other advantages above and beyond what it provides
for health-care delivery. Since its inception, UAB telehealth has saved
28,500,000 miles of driving to and from doctor's visits. That is
equivalent to the reduction in CO2 emission of 2,619
passenger vehicles off the road for an entire year, saving patient's
gas money, commute time, and time away from work and family. Alabama
gained 16,1470,00 dollars in productivity by patients being able to
work the times that otherwise would have been spent driving alone to
doctor's appointments. We are one institution that uses telehealth, but
multiply this by every institution, and you have improved
CO2 emissions and improved utilization of our fuel.
What do we need to do as a country to ensure that we continue to
deliver telehealth now and ensure its survival to fully develop its
potential within our national health-care delivery infrastructure and
ensure its availability to scale up during times in the future, such as
COVID-19?
1. The elimination of the geographic restrictions needs to be
permanent. Prior to COVID-19, patients had to do their
telehealth in a medical facility in a rural area. The COVID-19
pandemic removed this restriction, which will expire at the end
of 2024. I'll never forget a patient of mine who was unable to
walk who lived in Birmingham. His father would take him to the
clinic and was about to lose his job from driving his son to
and from clinic visits. The patient lived no more than 2 miles
from our clinic, but getting in and out of a vehicle and
parking close to our clinic was enough to make any clinic visit
a half-day event. He found out I was seeing patients through
telehealth and brought me an article in which I had been
featured. And he asked me, ``Is this for me?'' And the answer
was ``no'' at the time because he lived in an urban area.
Another example of the need for telehealth in urban areas
relates to transplants. UAB is the only transplant center in
the State, yet a patient in Mobile, AL, which is 4 hours away
but urban, had to drive to a rural county to receive their
transplant care. Why? Care for rare and ultrarare diseases can
sometimes only be found multiple States away. We all would want
our children to go to the ``expert.'' Yet if the geographic
restriction comes back, this would not be possible over
telehealth for those living in urban centers. Access to care
problems is not geographically restricted, so why should our
regulations be?
2. The elimination of the originating site requirement needs
to remain permanent. Delivery of telehealth care within brick-
and-mortar sites is a great way to care for patients who do not
have access to technology. However, the operational hurdles,
including contracting for space in external sites and
scheduling across systems and electronic medical records, are
not such that it can be the sole manner to deliver telehealth
services. The home is adequate and will continue to improve as
a site of care as the accessibility to in-home diagnostics
continues to improve.
3. Coverage for telehealth needs to continue at parity for in-
person visits and needs to be permanent. The delivery of
telehealth is not just a video visit with your provider. For
these visits to be efficient, the same staff is needed to
ensure the visit is a success. Someone has to schedule the
visit; someone has to do med reconciliation and, in many cases,
``room'' the patient electronically. Furthermore, there are
ongoing technology costs, including subscriptions to platforms,
information technology support, etc. Should the reimbursement
drop below parity, given the ongoing costs, providers will be
unable to provide telehealth visits, which will be a great
disservice to patients who now rely on technology as a lifeline
to good care.
4. Audio-only visits should continue to be covered. Although
video visits are a preferred method for delivering telehealth
services, not all patients can access video visits. Suppose a
provider attempts to get a patient on video due to technology
access. In that case, the patient cannot get on video; this is
documented, and care is rendered. That time should be
reimbursed commensurate with the time-based codes for in-person
visits. An hour's visit on the phone is still an hour of
provider time. Furthermore, physicians trying to care for the
most disparate of populations are going to be the hardest hit
financially by regulations that reduce reimbursement for audio
only telehealth. Unfortunately, the reality for some patients
is audio only care versus no care at all.
5. Controlled substances that are not Schedule 2 should be
allowed to be prescribed over telehealth. For many not in the
medical field, controlled substances immediately conjure images
of opioids and benzodiazepines. However, other medications are
included, and some may not realize that antiseizure medications
are in these categories. It does not make sense that a patient
with epilepsy, whom we have restricted from driving, cannot get
a prescription for their antiseizure medications over
telehealth when appropriate. Furthermore, data has shown that
suboxone, used to treat opioid addiction and prevent overdoses,
can safely and effectively be prescribed for a limited quantity
over telehealth, followed by quick in-person follow-up to
ensure access to this drug. My colleagues who treat OUD at UAB
were able to provide rapid access to addiction treatment and
overdose prevention via telehealth during the pandemic. Now,
regulatory barriers make it hard to get new patients, such as
those recently released from rehab or jail, into addiction
treatment using telehealth. Overdose deaths rose 11 percent in
AL last year. We must extend the lifeline of telehealth to halt
the overdose crisis.
6. Direct supervision of residents should also remain possible
via telehealth.
In closing, we must maintain and support telehealth through
permanent legislation as it is critical to the survival of rural
health, the future of our health-care system's ability to deliver
equitable care regardless of geography, and is integral to our ability
to deliver on the promise of value-based care. Just as important as its
importance to the structure of health-care delivery is that behind each
of these asks are human beings who have grown to rely on this
technology as a lifeline to care. Thank you.
______
Communications
----------
AARP
AARP, which advocates for the more than 100 million Americans age 50
and older, appreciates the Senate Committee on Finance's effort to
examine Medicare beneficiary access to telehealth services.
Access to telehealth provides convenience, protects against exposure to
infection, improves treatment adherence, enables chronic disease
management, and promotes independence and autonomy for people with
Medicare. Telehealth benefits can be particularly significant for older
adults in rural areas or underserved communities by reducing or
eliminating travel and wait times, distance and transportation
barriers, and certain travel or transportation costs. These individuals
face added barriers to care, including long distances and additional
costs, when visiting providers and specialists. In some cases, a
specialist or provider may be so far away that the distance is
prohibitive, in which case the person may forgo care altogether.
Overall, telehealth services are an important care-delivery tool and a
valuable complement for in-person care.
Telehealth can also support America's more than 48 million family
caregivers in their efforts to take care of their loved ones.
Telehealth may offer working or long-distance family caregivers an
alternative way to participate in their loved one's medical care. By
reducing travel, wait times, and costs associated with in-person care,
telehealth can also allow caregivers more time to tend to their own
needs, which can alleviate some of the stress linked to balancing
caregiving responsibilities with other obligations. Research has shown
that use of telehealth services by family caregivers results in better
physical and mental health, improved caregiving knowledge and skills,
and higher satisfaction in their caregiving roles.
The COVID-19 pandemic forced Medicare to quickly adapt to an increased
need for telehealth, often relying on waivers to allow for otherwise
impermissible care. AARP believes Medicare beneficiaries should
continue to be able to access care via telehealth beyond the current
December 31, 2024, waiver expiration. However, we urge Congress to act
deliberately and thoughtfully, rather than making all waivers and
flexibilities permanent with one fell swoop. Just because a service or
provider was permitted during the public health emergency does not mean
it should automatically continue without examination. We now have 3
years of data on which to evaluate the quality, value, and utilization
of telehealth services in Medicare. Decisions should be made for each
service code, each provider type, each modality, and each reimbursement
amount independently of their in-person counterpart, not writ large.
We know that older Americans use and have a favorable opinion of
telehealth. According to recent AARP research, half of adults age 50-
plus say they or a family member have used telehealth in the past 2
years. Yet a third of those who have experience with telehealth still
expressed concern that the quality of care is not as good as with in-
person care.\1\ As the Committee and Congress work to address permanent
access to telehealth in Medicare, we urge you to consider the
perspective of people with Medicare.
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\1\ Keenan, Teresa A. An Updated Look at Telehealth Use Among U.S.
Adults 50-Plus. Washington, DC: AARP Research, May 2022. https://
doi.org/10.26419/res.00535.001.
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Geographic and Originating Site Restrictions
AARP firmly believes that removing telehealth restrictions related to
location and geography are fundamental and foundational to increasing
access to care in the modern age. These restrictions prevent telehealth
from being used by people, providers, and facilities in urban and
suburban areas and prevent people with Medicare from receiving care at
home based on where they live. Similar restrictions placed on distant
sites should be permanently removed as well, to allow patient
engagement with Federally Qualified Health Centers and Rural Health
Centers. Additionally, eliminating Medicare restrictions should be done
in concert with reducing existing barriers to care elsewhere, such as
through greater investment in broadband and workforce, to ensure the
people and communities who have historically faced challenges accessing
care and who can most benefit from telehealth have the opportunity to
use it.
Telehealth Reimbursement
In general, payment for telehealth services should be sufficient to
support telehealth use by providers and raise value for patients.
Medicare and other payers should thoughtfully consider how to reimburse
clinicians and other telehealth providers. This includes accounting for
the cost of providing telehealth; the need to support patients' ongoing
access to telehealth with compensation that fairly incentivizes its
use; the need to avoid unnecessary additional costs; and the
efficiencies telehealth may afford. Reimbursement for telehealth
services should be independently calculated the same way as in-person
services, taking into account the same relative value variables as in-
person service codes. The cost of performing a telehealth service may
not be the same as the cost of performing its in-person counterpart,
thus it should not be reimbursed the same.
Quality and Program Integrity
AARP supports Congress removing statutory prohibitions to telehealth in
Medicare and affirming the Centers for Medicare & Medicaid Services
authority to implement telehealth coverage. But we believe that before
CMS makes the expanded list of services and providers permanent, we
must understand their impact on quality of care and outcomes, as well
as on the program integrity and financial standing of Medicare. CMS has
laid out a framework to do so through the Physician Fee Schedule
regulatory process, and we urge both legislators and policymakers to
not circumvent this and other processes intended to ensure quality and
safety.
Relatedly, requiring a pre-existing relationship with a provider prior
to a telehealth visit is an important patient safety standard. However,
there are many instances in which the requirement becomes a barrier to
care that can harm patients rather than protect them. Policy should be
informed by clinical standards of care and determined for each service.
Furthermore, many services, particularly mental health services, can be
safely and effectively delivered via audio-only, rather than audio-
video. Requiring a live video link can put an undue burden and create
barriers to care for Medicare beneficiaries. Many people with Medicare
do not have the technological capacity or understanding to operate a
live video link. Others do have the know-how, but are stymied by a lack
of broadband, bandwidth, and connectivity needed to maintain a stable
video connection. Overall, we caution against making straight
comparisons between in-person services and telehealth services, between
different modalities, and between the providers delivering in-person
versus the providers delivering care remotely. Ensuring high-quality,
high-value care requires a more nuanced approach.
Conclusion
The recent Medicare telehealth waivers and flexibilities have clearly
demonstrated the usefulness and promise of health care delivered via
telehealth. People with Medicare risk losing the convenience and
reliability of telehealth services when coverage ends in December 2024.
We are grateful that you are working to address Medicare telehealth
coverage well in advance of the looming deadline. Fortunately, there is
much to build on already. For instance, we have endorsed S. 2016, the
CONNECT for Health Act. We recommend Congress take up this and other
legislation that will allow older Americans access to the array of
tools and services available for delivering high-quality, high-value
care.
Thank you for the opportunity to provide AARP's perspective on
improving Medicare's coverage of telehealth services. We look forward
to working with you to address this important issue and ensure
continued convenient access to quality health care for older Americans.
For further information contact:
Andrew Scholnick
Health Access and Affordability
Government Affairs
[email protected]
______
Alliance for Connected Care
1100 H Street, NW, Suite 740
Washington, DC 20005
Dear Health Subcommittee Chair Cardin (D-MD), Health Subcommittee
Ranking Member Daines (R-MT), and Members of the Senate Finance Health
Subcommittee:
The Alliance for Connected Care (``the Alliance'') welcomes the
opportunity to provide input to the Committee hearing on ``Ensuring
Medicare Beneficiary Access: A Path to Telehealth Permanency.'' We
applaud your continued leadership and critical role in ensuring
continued telehealth access post-COVID-19 public health emergency. We
look forward to working with you to ensuring permanent access to
telehealth.
The Alliance is dedicated to improving access to care through the
reduction of policy, legal and regulatory barriers to the adoption of
telemedicine and remote patient monitoring. Our members are leading
health care and technology companies from across the spectrum,
representing health systems, health payers, and technology innovators.
The Alliance also works in partnership with an Advisory Board of more
than 50 patient and provider groups, including many types of clinician
specialty and patient advocacy groups who wish to better utilize the
opportunities created by telehealth.
The experience during COVID-19 has pushed forward a revolution in
consumer attitudes toward virtual care. Polling data from the
University of Michigan \1\ showed that 64 percent of those surveyed in
June 2020 were comfortable with using videoconferencing technology for
any purpose, up from 53 percent in May 2019. A major study of more than
4 million primary care encounters from MedStar Health, Stanford Health
Care, and Intermountain Health found that telehealth did not increase
utilization, but rather served as a substitute for certain in-person
encounters. In the same study, telehealth was mostly utilized for
patients whose medical needs required multiple primary care visits
during each year, suggesting that these telehealth encounters enabled
follow-up for patients. A study from Epic Research,\2\ also found
similar results. A subsequent study \3\ found that a significant share
of physicians continue to heavily rely on telehealth services amid the
general decline in telemedicine use post-COVID. Other studies \4\ found
similar results. These findings show us that fears about
overutilization of telehealth in Medicare are unfounded, as usage rates
have declined to a small, steady proportion of visits. Patients and
health care practitioners have adopted telehealth as needed, and are
using it appropriately. According to an Alliance-commissioned Medicare
claims data analysis,\5\ the average per service cost of an E&M
telehealth visit to the Medicare program is less than in-person
services by approximately 20%. The reason for this difference was that
telehealth clinicians generally billed shorter visit codes than in-
person providers.
---------------------------------------------------------------------------
\1\ https://labblog.uofmhealth.org/rounds/telehealth-visits-
skyrocket-for-older-adults-but-concerns-and-barriers-remain.
\2\ https://epicresearch.org/articles/fewer-in-person-follow-ups-
associated-with-telehealth-visits-than-office-visits.
\3\ https://jamanetwork.com/journals/jamanetworkopen/fullarticle/
2806867.
\4\ https://divisionofresearch.kaiserpermanente.org/telehealth-
users/.
\5\ https://connectwithcare.org/medicare-telehealth-analysis/.
Telehealth research continues to align in its findings and future
telehealth research in the few years after the public health emergency
will continue to demonstrate use for telehealth. Policymakers have more
than enough data to see the benefits of telehealth and consider a
permanent pathway to ensure that telehealth continues to be available
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and accessible for Medicare beneficiaries.
The Alliance will focus comments on (1) recommendations for a permanent
telehealth expansion that Congress should consider--including steps to
ensure equitable access; (2) other non-Medicare recommendations that we
believe Congress should prioritize, and (3) while we generally do not
believe additional telehealth guardrails are needed, we offer some
options here that would be operationally feasible for health care
organization to implement without significantly disrupting patient
access to care.
Top Telehealth Priorities
The Alliance believes that Congress should expand access of Medicare
telehealth by permanently lifting the barriers of 1834(m). It is
important to note that the removal of these broad statutory
restrictions does not mean the removal of guardrails on Medicare
services. Even without specific restrictions on telehealth, the full
array of payment, cost, quality, and fraud prevention powers afforded
to the Centers for Medicare and Medicaid Services (CMS) would be
available to ensure Medicare only paid for high-quality, clinically
appropriate telehealth care.
Below, we outline several recommendations that Congress should consider
to permanently expand telehealth to Medicare beneficiaries.
Core Statutory Challenges in Medicare
1. Expand patient access to telehealth services by removing
geographic and originating site limitations to enable patients to
communicate remotely with their providers regardless of location. The
Alliance supports legislation to eliminate the originating site
construct completely--rather than just adding the ``home.'' Section
1834(m) of the Social Security Act has long been a barrier to expanding
Medicare beneficiaries' access to telemedicine due to stringent
originating site and geographic location restrictions. Evidence has
shown that telemedicine is not only necessary in rural and underserved
areas, but also in urban and suburban communities where mental health
care may not be accessible, convenient, or affordable. Furthermore,
Medicare/Medicaid populations traditionally face significant
transportation barriers such as affordability and physical impairments,
making it more difficult to get to an in-
person location. While requiring specific sites of care for telehealth
may have made sense when technology was new and unreliable, the
commercial market today is effectively deploying telehealth nationwide.
There is no reason for our most vulnerable populations to have less
access to care. In addition to patients, providers also request this
flexibility. An Alliance 2022 survey \6\ found that 8 in 10
practitioners say that retaining telehealth for health care
practitioners would make them, personally, more likely to continue
working in a role with such flexibility.
---------------------------------------------------------------------------
\6\ https://connectwithcare.org/alliance-news/patients-and-
practitioners-agree-telehealth-is-important-for-patient-access-health-
care-workforce/.
2. Remove distant site provider list restrictions to allow all
Medicare providers who deliver telehealth-appropriate services to
provide those services to beneficiaries through telehealth when
clinically appropriate and covered by Medicare--including physical
therapists, occupational therapists, speech-
language pathologists, social workers, and others. Additionally, direct
CMS to work to ensure that in-person payment models, such as those in
which a
facility/provider organization bills on behalf of a care-team can be
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fully compatible with virtual care environment.
3. Ensure Federally Qualified Health Centers, Critical Access
Hospitals, and Rural Health Clinics can furnish telehealth in Medicare
and be reimbursed fairly for those services, despite unique payment
characteristics and challenges for each. Current payment structures
often do not capture the unique billing characteristics of telehealth
and remote patient monitoring services and need to be updated to better
align with the broader CMS payment environment.
4. Allow the Centers for Medicare and Medicaid Services to cover
audio-only telehealth services where necessary to bridge gaps in access
to care. Audio-only telehealth visits should continue to be an option
for patients who lack access to the resources needed to participate in
video-based telehealth. The digital divide is well documented and
congressional plans are in place to help narrow its impact over the
next 5 years. We collectively acknowledge that patients across a wide
range of demographic groups do not have sufficient internet access,
device access, or digital skills to connect with their clinicians over
a stable video connection. In these instances, patients and providers
should have the flexibility to choose when an audio-only telehealth
visit is both clinically appropriate and preferred by the patient. This
would be consistent with prior CMS language emphasizing the importance
of patient choice. We anticipate that CMS would also maintain a list of
services that were appropriate for audio-only care, as it has done for
the past several years.
Additional Medicare Challenges
5. Allow providers rendering telehealth services from their home
to offer services without reporting their home address on their
Medicare enrollment or billing paperwork.\7\ CMS allowance for
practitioners to render telehealth services from their home without
reporting their home address on their Medicare enrollment or billing
paperwork will end on December 31, 2024. While these changes are within
CMS's regulatory authority, we look forward to working with members of
the Finance Committee to ensure CMS prioritizes the needs of telehealth
providers in addition to patients.
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\7\ https://connectwithcare.org/provider-location/.
6. Drive better and more coordinated care for those with chronic
disease through adequate reimbursement and flexibility supporting
greater use of remote patient monitoring (RPM) technology.\8\ Remote
patient monitoring has a huge potential to reduce Medicare expenditures
through better health and avoided hospital admissions. Geographic
variation results in lower Medicare payments for remote patient
monitoring in rural areas, despite many costs being higher in these
areas where connectivity is more difficult. While these changes are
within CMS's regulatory authority, we request that members of the
Finance Committee prioritize work to expand rural access to remote
patient monitoring.
---------------------------------------------------------------------------
\8\ https://connectwithcare.org/remote-patient-monitoring/.
7. Facilitate the removal of remaining telehealth restrictions on
alternative payment models, Accountable Care Organization's (ACO)
telehealth flexibility is limited a narrow set of ACOs with downside
risk and prospective assignment--even though other tools apply to all
ACOs. Since all participants in the Medicare Shared Savings Program are
being held accountable for quality, cost, and patient experience, all
of them should have flexibility to use telehealth tools to deliver
care. We recommend eliminating Sec. 1899. [42 U.S.C. 1395jjj] (I)(2)
requirements limiting participation to a select set of ACOs. We believe
CMS may already have the statutory authority to make these changes
under 42 U.S.C. 1315a(d)(1) and 42 U.S.C. 1395jjj(f) if directing the
use of authority instead would keep the score down.
Other Telehealth Challenges
1. Encourage Additional Care Across State Lines \9\--While we
recognize that licensure is a state, not federal authority, we believe
there is much that Congress can do to incentivize the adoption of
licensure reciprocity among states. We strongly encourage Congress to
support legislation and funding that helps patients receive access to
care, even when that care is not available in their state. One option
would be to provide incentives for states to adopt the Uniform Law
Commission's Telehealth Act.\10\ Simultaneously, there could be
specific federal telehealth licensure carve outs similar to those
successfully enacted by the Veterans Administration for VA patients,
the Department of Defense for military spouses practicing medicine when
deployed, and by Sports Medicine physicians to care for players even
when they travel to another state. These telehealth licensure carve
outs would allow for recognition of the providers home license when
they virtually care for out of state patients under certain clinical
scenarios such as organ donation, clinical trials, rare medical
diseases, student health, and established patients. A multidisciplinary
team of experts from leading national institutions developed a
consensus statement \11\ outlining these and other possible licensure
solutions.
---------------------------------------------------------------------------
\9\ https://connectwithcare.org/cross-state-licensure/.
\10\ https://www.uniformlaws.org/committees/community-
home?communitykey=2348c20a-b645-4302-aa5d-9ebf239055bf.
\11\ https://chlpi.org/resources/consensus-statement-for-
telehealth-licensure-reforms/.
2. Continue Oversight of the Drug Enforcement Administration
(DEA)'s Regulations Restricting the Prescribing of Controlled
Substances via Telemedicine \12\--Special registration to prescribe
controlled substances through telemedicine was originally called for in
the Ryan Haight Act of 2008.\13\ After 15 years of several
congressional mandates to promulgate regulations related to a Special
Registration for Telemedicine, the DEA has still not issued permanent
policy. On October 6, 2023, the DEA extended temporary flexibility for
telehealth prescribing through December 31, 2024. Its proposed rule,
offered in the spring of 2023, would cut off access to care for
millions of Americans and must not be finalized as proposed.
---------------------------------------------------------------------------
\12\ https://connectwithcare.org/dea-prescribing-of-controlled-
substances/.
\13\ https://www.congress.gov/110/plaws/publ425/PLAW-
110publ425.pdf.
3. Make Permanent the HDHP/HSA Telehealth Safe Harbor Created in
Section 3701 of the CARES Act.\14\ This provision allows Americans with
health savings account (HSA) eligible high deductible health plans
(HDHP) to access telehealth services before their annual deductible was
met, ensuring that employers and plans could support patients that were
leveraging virtual care to access a range of critical health care
services during the pandemic. This has provided important virtual care
for 32 million individuals with these plans. As such, we strongly urge
the Finance Committee to pass S. 1001--the Telehealth Expansion Act of
2023 as introduced by Senators Daines and Cortez Masto.
---------------------------------------------------------------------------
\14\ https://connectwithcare.org/hdhp-telehealth/,
4. Allow Employers to Offer Telehealth Benefits for Seasonal and
Part-time Workers. Increasing access to some telehealth benefits for
part-time employees, seasonal workers, interns, new employees in a
waiting period can be a meaningful way to support workers--as long as
this access supplements health insurance purchased by that individual
or a family member. We urge Congress to find a way to continue expanded
access that has been experienced by workers over the past several
years.
Recommendations for Fraud, Waste and Abuse
The Alliance understands that with change sometimes comes risk, and
that Congress holds ultimate authority for protecting the Medicare
program. We understand and respect this responsibility. We also believe
that, using the data we are collecting about the provision of
telehealth services during the PHE, the Medicare program and the Office
of the Inspector General at HHS will be able to target and
differentiate nearly all fraudulent behavior. Congress must trust this
capability and authority, rather than creating barriers to access
between Medicare beneficiaries and critical health services.
The Alliance and its members strongly believe that an in-person
requirement is never the right guardrail for a telehealth service.
Requiring an in-person visit constrains telehealth from helping
individuals that are homebound, have transportation challenges, live in
underserved areas, etc. It does not constrain those using telehealth
for convenience. This creates a perversion of the Medicare payment
system by reducing access for those who need it most, while allowing
access for others. We cannot create a guardrail that is an access
barrier between patients and their clinicians--it will lead to harm the
most vulnerable and access-constrained Medicare beneficiaries.
We also believe it is important to note that nearly all of the fraud
Congress may seek to prevent is fraud that mirrors activities currently
occurring during in-person care. These concerns include fraudulent
Medicare enrollment, false claims, fake patients, and durable medical
equipment (DME) prescribing. All of these issues are problems for the
Medicare program--and should be addressed as Medicare fraud problems.
They are not new problems for telehealth services. Therefore, an in-
person requirement would hinder legitimate telehealth providers while
doing very little to stop fraudulent actors. Instead of creating
barriers to services for Medicare beneficiaries, Congress must empower
CMS to address fraudulent actors.
With the understanding the Congress may still want to pursue additional
guardrails against fraud, waste, and abuse as part of telehealth
legislation, we offer the following alternatives. Please note that many
of these are simple regulatory changes, and could be issued as
recommendations to CMS.
Develop restrictions to prevent the exploitation of telehealth
services by soliciting telemarketers. In combination with an enhanced
Medicare provider enrollment process, we believe that a restriction on
the solicitation would provide significant protection against durable
medical equipment (DME) fraud actors exploiting telehealth services to
drive improper DME sales. This restriction would not apply to patient
outreach that: arises out of an established patient-provider
relationship and is conducted for purposes of appropriate management of
acute or chronic disease; arises out of a Medicare enrolled provider's
referral to a new provider or supplier for appropriate items or
services; or meets an otherwise applicable marketing exception under
HIPAA or other federal or state consumer protection laws. We do not
believe that this restriction would significantly hinder appropriate
healthcare organization marketing or existing healthcare delivery
models.
Strengthen the Medicare provider enrollment process for
telehealth:
Require new virtual-only providers to indicate
their intent to bill only virtual services during the
enrollment process. Subject these providers to enhanced
scrutiny and/or audits.
Consider additional private-sector
accountability tools for virtual-only providers, such as
certifications. Such certifications could include education on
billing and the avoidance of fraud and abuse in billing for
telehealth services.
To provide telehealth services to a Medicare
beneficiary, all providers must indicate the intent to do so
during enrollment. Phase in for currently enrolled providers.
Establish clear billing guidelines for services arising out of
telehealth service/CTBS.
In place of an in-person requirement prior to prescribing,
consider alternate restrictions on DME. While we recognize and support
efforts to address DME fraud, including when it exploits virtual care
tools, we believe there are better tools to address this concern:
Temporarily allow prescribing (for 2-3 years)
with enhanced monitoring tools. At the end of this period
leverage data collected to design any restrictions.
Enhanced monitoring tools should identify
providers with unusual, high-volume DME prescribing patterns
for audits or investigation. Initiate early communication with
unusually high-volume providers that their volume is unusually
high even before expending resources on an investigation.
Require that the prescribing of DME be tied to
documented and auditable clinical criteria.
Require DME to be tied to a service code/
submission (even if telehealth not billable)--making it easier
for the Medicare program to track.
Strengthen existing HHS/OIG efforts to fight fraud and guide
health care organizations. The Office of the Inspector General at HHS
has been effective in combating DME fraud that exploited virtual care
tools. We should maintain and enhance that authority through additional
resources. OIG must also issue telehealth compliance guidance, inviting
input and opportunity to comment from the Alliance for Connected Care,
the American Health Lawyers Association and other interested private
sector groups before publication, to healthcare organizations to help
prevent and mitigate unintentional mistakes related to Medicare
telehealth billing.
The Alliance greatly appreciates the Senate Finance Committee's
leadership in working to ensuring permanent access to telehealth. We
look forward to working with you to develop and advance bipartisan
legislation to enhance telehealth access for Medicare beneficiaries. If
you have any questions or would like to hear from Alliance member
experts on these topics, please do not hesitate to contact Chris Adamec
at [email protected].
Sincerely,
Krista Drobac
Executive Director
______
Alzheimer's Association and Alzheimer's Impact Movement
655 15th Street, NW, Suite 500
Washington, DC 20005
The Alzheimer's Association and Alzheimer's Impact Movement (AIM)
appreciate the opportunity to submit this statement for the record for
the United States Senate Committee on Finance, Health Subcommittee
hearing on ``Ensuring Medicare Beneficiary Access: A Path to Telehealth
Permanency.'' The Association and AIM thank the Subcommittee for its
continued leadership on issues important to the millions of people
living with Alzheimer's and other dementia and their caregivers.
This statement highlights the importance of telehealth policies that
continue to help people living with Alzheimer's and other dementia
access timely and high-quality care, including efforts to expand
capacity for health outcomes through Project ECHO, and the expansion of
Medicare and Medicaid coverage of certain telehealth services. While
greater coverage of telehealth services has allowed individuals living
with Alzheimer's and other dementia to receive consistent care in
numerous settings, we also encourage the Subcommittee to support
innovative efforts to increase access to telehealth and telemedicine
for Medicare beneficiaries for whom access to broadband or technology
is problematic.
Founded in 1980, the Alzheimer's Association is the world's leading
voluntary health organization in Alzheimer's care, support, and
research. Our mission is to eliminate Alzheimer's and other dementia
through the advancement of research, to provide and enhance care and
support for all affected, and to reduce the risk of dementia through
the promotion of brain health. AIM is the Association's advocacy
affiliate, working in a strategic partnership to make Alzheimer's a
national priority. Together, the Alzheimer's Association and AIM
advocate for policies to fight Alzheimer's disease, including increased
investment in research, improved care and support, and the development
of approaches to reduce the risk of developing dementia.
Expansion of Telehealth Service Coverage
The Alzheimer's Association and AIM are grateful that the Centers for
Medicare & Medicaid Services (CMS) permanently expanded Medicare and
Medicaid coverage for many telehealth services important to persons
living with dementia and caregivers. For example, CMS has permanently
expanded coverage for numerous codes that are beneficial to people
living with Alzheimer's and other dementia so that they can continue
accessing care in settings that best serve their unique needs. In
particular, the Alzheimer's Association and AIM supported CMS's
decision to allow for telehealth coverage of care planning CPT code
99483. Care planning is critical for people with cognitive impairment
under normal circumstances to help them manage comorbid conditions and
make decisions about long-term care and support services, among others.
Ensuring that a plan is established, documented, and updated is now
more important than ever. Making this service available via telehealth
will improve access to care planning for this vulnerable population. To
that end, we also thank Congress for passing the bipartisan Improving
HOPE for Alzheimer's Act (S. 880/H.R. 1873), which continues to educate
clinicians on the importance and availability of this crucial Medicare
care planning service.
Finally, we appreciate CMS's flexibility in allowing telehealth
technology to be used in home health delivery. Thirty-two percent of
individuals using home health services have Alzheimer's or other
dementia. The ability to receive care in the home decreases visits to
unfamiliar places that may cause agitation in people with dementia and
can ease some burden on caregivers. This increased flexibility can
reduce interruptions in access to this kind of quality care.
Expanding Capacity for Health Outcomes (Project ECHO)
First, we ask that the Subcommittee support the expansion of and
continued investment in the use of technology-enabled collaborative
learning and capacity-building models, often referred to as Project
ECHO. These models use a hub-and-spoke approach by virtually linking
expert specialist teams at a ``hub'' with the ``spokes'' of health
providers in local communities to increase on-the-ground expertise.
Using case-based learning, Project ECHO models can improve the capacity
of providers, especially those in rural and underserved areas, on how
to best meet the needs of people living with Alzheimer's and other
dementia. In 2018, the Alzheimer's Association launched an Alzheimer's
and Dementia Care Project ECHO Network--a highly successful
telementoring program that has trained more than 330 health care
professionals from 116 primary care practices and more than 250
professional care providers from 91 long-term care communities in a
free continuing education series of interactive, case-based video
conferencing sessions across the United States.
Project ECHO dementia models are helping primary care physicians in
real-time understand how to use validated assessment tools appropriate
for early and accurate diagnoses, educate families about the diagnosis
and home management strategies, and help caregivers understand the
behavioral changes associated with Alzheimer's. Participants express
high levels of satisfaction with the program and the majority (95
percent) of primary care clinicians who join the Alzheimer's and
Dementia Care ECHO program said the quality of care they provide
improved as a result of their experience. Long-term and community-based
care providers also benefit from Project ECHO dementia programs. Recent
evaluations from the Alzheimer's Association demonstrate statistically
meaningful increases in confidence in working with people living with
dementia and overall disease knowledge post-ECHO completion and 92
percent of long-term care participants felt that the information gained
through participation was valuable in their work.
In 2020, the Alzheimer's Association launched the Alzheimer's and
Dementia Care ECHO Global Collaborative. We are engaging partners
across the world using the ECHO model to increase equitable access to
dementia detection and person-centered dementia care. This group meets
quarterly and has identified three key working objectives: (1) increase
the use of Project ECHO for Alzheimer's and other dementia care; (2)
increase evidence around the efficacy of the ECHO model for dementia;
and (3) increase and advance policy and funding support for ECHO
programs focused on dementia. This robust network currently includes 18
partners spanning four continents, with nine additional organizations
exploring the ECHO model for dementia.
One partner in the Alzheimer's and Dementia Care ECHO Global
Collaborative is the Dementia ECHO Indian Country Program. The Indian
Country Program is designed to support clinicians at the Indian Health
Service and caregivers to strengthen the knowledge and care around
dementia tribal patients. These ECHO programs are interactive online
learning environments where clinicians and staff serving American
Indian and Alaska Native patients connect with peers, engage in
didactic presentations, collaborate on case consultations, and receive
mentorship from clinical experts from across Indian Country. As a
result, these ECHO programs enable primary care providers to better
understand Alzheimer's and other forms of dementia, emphasize high-
quality, person-centered care in community-based settings, and aim to
improve health outcomes while reducing geographic barriers and the cost
of care through a team-based approach.
Project ECHO was especially crucial during the COVID-19 pandemic, where
the models played an important role in how health providers, public
health officials, and scientists in real-time share best practices and
information. For example, the Agency for Healthcare Research and
Quality (AHRQ) established the AHRQ ECHO National Nursing Home COVID-19
Action Network of over 100 ECHO hubs to train nursing home staff on
COVID testing, infection prevention, safety practices to protect
residents and staff, quality improvement, and how to manage social
isolation. The Network received nearly $237 million in federal funding
during the pandemic, and, as a result, was able to reach nearly two-
thirds of nursing homes in the United States. Investing in Project ECHO
models is an innovative way to improve the capacity of a quality
healthcare workforce to meet the needs of a growing aging population,
including primary care physicians, specialists, and long-term care
workers.
Conclusion
The Alzheimer's Association and AIM appreciate the steadfast support of
the Subcommittee and its continued commitment to advancing legislation
important to the millions of families affected by diseases such as
Alzheimer's and other dementia. We look forward to working with the
Subcommittee and other members of Congress in a bipartisan way to
advance policies that would help this vulnerable population receive
consistent, high-quality care through Medicare and Medicaid coverage of
certain telehealth services and the continued expansion of Project ECHO
models.
______
American Academy of Family Physicians
1133 Connecticut Avenue, NW, Suite 1100
Washington, DC 20036-1011
202-232-9033
Fax: 202-232-9044
https://www.aafp.org/
Dear Chairman Cardin and Ranking Member Daines:
On behalf of the American Academy of Family Physicians (AAFP),
representing more than 129,600 family physicians and medical students
across the country, I write to thank you both for your bipartisan
leadership to address issues impacting family physicians and their
patients through today's hearing entitled ``Ensuring Medicare
Beneficiary Access: A Path to Telehealth Permanency.''
As the usual source of care for patients across the lifespan, family
physicians are uniquely trained to practice across care settings and
meet the needs of their communities, including offering care by their
patient's preferred and most appropriate modality. This has more
frequently included care delivered via telehealth, which has seen
increased utilization as a result of the pandemic. Telehealth claims
have jumped from 0.1% in 2019 to about 5% at the end of 2021.\1\
According to a recent AAFP survey, 9 in 10 family physicians practice
telehealth today.
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\1\ Shaver, J. The State of Telehealth Before and After the COVID-
19 Pandemic. Prim Care. 2022 Dec;49(4):517-530. doi: 10.1016/
j.pop.2022.04.002. Epub 2022 Apr 25. PMID: 36357058; PMCID: PMC9035352.
The AAFP supports \2\ expanded use of telehealth and telemedicine as an
appropriate and efficient means of improving health, when conducted
within the context of appropriate standards of care. Telehealth
technologies can enhance patient-physician collaborations, increase
access to care, improve health outcomes, and decrease costs when
utilized as a component of, and coordinated with, longitudinal care.
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\2\ https://www.aafp.org/about/policies/all/telehealth-
telemedicine.html.
Any permanent expansion of telehealth benefits should be structured to
not only increase access to care but also promote high-quality,
comprehensive, continuous care, as outlined in the joint principles \3\
for telehealth policy put forward by the AAFP, the American Academy of
Pediatrics and the American College of Physicians. The appropriateness
of a telemedicine service should be dictated by the standard of care
and not by arbitrary policies. Available technology capabilities as
well as an existing physician-patient relationship impact whether the
standard of care can be achieved for a specific patient encounter type.
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\3\ https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/
telehealth/LT-Congress-TelehealthHELP-070120.pdf.
As telemedicine services are expanded and utilized to achieve the
desired aims, it is also imperative that outcomes are closely monitored
to ensure disparities in care are not widened among vulnerable
populations. Policies should acknowledge the geographical and
socioeconomic disparities that exist and could be exacerbated by the
improper adoption of telehealth if not explicitly addressed. Access to
broadband is a social determinant of health. All patients and practices
should have broadband access to support delivery of telehealth services
in accordance with AAFP's policy on Health Care for All.\4\ It is with
these considerations in mind that the AAFP offers the following policy
recommendations in response to today's hearing:
---------------------------------------------------------------------------
\4\ https://www.aafp.org/about/policies/all/health-care-for-
all.html.
---------------------------------------------------------------------------
Promoting Patient-Physician Relationships
Telehealth, when implemented thoughtfully, can improve the quality and
comprehensiveness of patient care, and expand access to care for rural
and under-resourced communities and vulnerable populations. As
discussed in the Academy's comments \5\ on the CY24 Medicare Physician
Fee Schedule proposed rule and our aforementioned joint principles, the
AAFP strongly believes telehealth policies should advance care
continuity and the patient-physician relationship.
---------------------------------------------------------------------------
\5\ https://www.aafp.org/content/dam/AAFP/documents/advocacy/
payment/medicare/LT-CMS-MedicarePhysicianFeeSchedule24ProposedRule-
090623.pdf.
Telehealth should also enable higher-quality, more personalized care by
making care more convenient and accessible for patients. Expanding
telehealth services in isolation, without regard for a previous
patient-physician relationship, medical history, or the eventual need
for a follow-up hands-on physical examination, can undermine the
central value offered by a usual source of primary care, a continuous
and comprehensive patient-physician relationship, increase
fragmentation of care, and lead to the patient receiving suboptimal
care. Responsible care coordination is necessary to ensure patient
safety and continuity of care for the immediate condition being
---------------------------------------------------------------------------
treated, and it is necessary for effective longitudinal care.
The AAFP strongly believes telehealth is most appropriate when provided
by a patient's usual source of care. We have significant concerns about
the rapid proliferation of direct-to-consumer (DTC) telehealth vendors
and the resulting interference with the established patient-physician
relationship. In the last several years we've seen new and different
types of DTC telehealth vendors emerge, including many for-profit
start-ups that market themselves in ways that lead a consumer to
believe they are providing true, person-centered health care. The
dangers of these types of companies extends beyond disrupting the
established patient-physician relationship but can range from misusing
patient data to making patients vulnerable to medical misinformation
and can even lead to patient harm.
Studies have shown that DTC telehealth can lead to increased
utilization and may ultimately increase overall health care spending.
Meanwhile, in July 2022, the Office of the Inspector General (OIG)
released a Special Fraud Alert \6\ regarding fraud schemes where
telemedicine companies offer kickbacks for prescribing medically
unnecessary items and services for individuals with whom the clinician
often does not have a relationship. As noted by the OIG, ``These types
of volume-based fees not only implicate and potentially violate the
Federal and anti-kickback statute, but they also may corrupt medical
decision-making, drive inappropriate utilization, and result in patient
harm.''
---------------------------------------------------------------------------
\6\ https://oig.hhs.gov/documents/root/1045/sfa-telefraud.pdf.
The AAFP remains concerned about the lack of regulation and
transparency DTC telehealth companies are subject to and how that might
impact patient care and outcomes. DTC telehealth cannot replace in-
person care and is not an adequate replacement for a longitudinal
patient-physician relationship, especially for patients with complex
---------------------------------------------------------------------------
medical conditions.
In light of these concerns, the AAFP supports \7\ the implementation of
telehealth coverage guardrails to protect the quality and continuity of
care delivered virtually, such as requiring an established patient
relationship for some telehealth services. Ensuring beneficiaries
receive telehealth services from a clinician that knows them and can
access their health record will help ensure patients receive
appropriate care, including in-person services when needed.
---------------------------------------------------------------------------
\7\ https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/
vaccines/LT-HHS-PHEUnwinding-061722.pdf.
A report \8\ from the HHS Office of the Inspector General found that 84
percent of Medicare fee-for-service telehealth visits are already being
provided by clinicians who have an established relationship with the
beneficiary. Other studies indicate \9\ patients prefer telehealth
services provided by their usual source of care. Implementing
additional guardrails would help ensure high-quality services are being
delivered to beneficiaries without unduly restricting access to care,
while also safeguarding program integrity.
---------------------------------------------------------------------------
\8\ https://oig.hhs.gov/oei/reports/OEI-02-20-00521.pdf.
\9\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5704580/.
---------------------------------------------------------------------------
Removal of Existing Medicare Restrictions
The Academy has advocated in support of permanently removing the
current section 1834(m) geographic and originating site restrictions to
ensure that all Medicare beneficiaries can continue to access care at
home. The COVID-19 pandemic has demonstrated that enabling physicians
to virtually care for their patients at home can not only reduce
patients' and clinicians' risk of exposure and infection but also
increase access and convenience for patients, particularly those who
may be homebound or lack transportation. Telehealth visits can also
enable physicians to get to know their patients in their home and
observe things they normally cannot during an in-office visit, which
can contribute to more personalized treatment plans and better referral
to community-based services.
Further, the AAFP supports the removal of remaining telehealth
restrictions on alternative payment models. Currently, telehealth
flexibility is limited to a narrow set of Accountable Care
Organizations (ACOs) with downside risk and prospective assignment--
even though other tools apply to all ACOs. Since all participants in
the Medicare Shared Savings Program are being held accountable for
quality, cost, and patient experience, they should all have the
flexibility to use telehealth tools to deliver care.
Telehealth for Mental and Behavioral Health
The COVID-19 public health emergency (PHE) transformed access to mental
and behavioral health care via telehealth, making it possible for many
patients to be connected to appropriate clinicians and treatment that
had otherwise been unavailable to them due to financial, geographic,
coverage, or other barriers. As PHE flexibilities end, we strongly urge
that Congress implements policies to minimize disruptions in access to
tele-mental and behavioral health care.
The AAFP has consistently \10\ advocated to Congress to permanently
remove the in-person requirement for tele-mental health services for
Medicare beneficiaries. Evidence has shown that telehealth is an
effective modality for providing mental and behavioral health
services.\11\ Meanwhile, family physicians report that persistent
behavioral health workforce shortages create significant barriers to
care for their patients. Arbitrarily requiring an in-person visit prior
to coverage of telemental health services will unnecessarily restrict
access to behavioral health care.
---------------------------------------------------------------------------
\10\ https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/
misc/LT-SenateFin
Cmte-BHI-111521.pdf.
\11\ Pew Trust. (2021, December 14). State Policy Changes Could
Increase Access to Opioid Treatment via Telehealth | The Pew Charitable
Trusts. https://www.pewtrusts.org/en/research-andanalysis/issuebriefs/
2021/12/state-policy-changes-could-increase-access-to-opioid-treatment-
via-telehealth.
As acknowledged in the AAFP's recent comments \12\ to the Drug
Enforcement Administration (DEA), the in-person connection between a
physician and patient can provide a valuable touchpoint for patients
receiving Medications for opioid use disorder (MOUD) and other opioid
use disorder (OUD) treatment services. However, existing shortages of
clinicians prescribing buprenorphine for OUD, as well as numerous other
barriers faced by patients with OUD, will prevent many patients from
being able to obtain an in-person visit, particularly within the DEA's
proposed 30-day timeframe. To that end, we strongly urge against
requiring an in-person exam for prescribers of buprenorphine for
treatment of OUD, given evidence in support of telehealth, limited
access to OUD treatment prescribers, and relatively lower rates of
buprenorphine diversion.
---------------------------------------------------------------------------
\12\ https://www.aafp.org/content/dam/AAFP/documents/advocacy/
health_it/telehealth/LT-DEA-TelehealthBuprenorphine-032923.pdf.
While an in-person evaluation may be necessary for other primary care
treatment (and as noted above, the AAFP encourages their requirement
for certain other services), data shows that buprenorphine prescribing
is particularly well-suited for
virtual-only visits. Telehealth initiation of and continued treatment
with buprenorphine has shown greater treatment retention, reduced
illicit opioid use, improved access to treatment, greater patient
satisfaction, and reduced healthcare costs.\13\,
\14\, \15\
---------------------------------------------------------------------------
\13\ Vakkalanka, J.P., Lund, B.C., Ward, M.M. et al. Telehealth
Utilization Is Associated with Lower Risk of Discontinuation of
Buprenorphine: a Retrospective Cohort Study of US Veterans. J Gen
Intern Med 37, 1610-1618 (2022). https://doi.org/10.1007/s11606-021-
06969-1.
\14\ Congressional Research Service, ``Broadband Loan and Grant
Programs in the USDA's Rural Utilities Service.'' March 22, 2019.
Accessed online: https://sgp.fas.org/crs/misc/RL33816.
pdf.
\15\ ``Ensuring the Growth of Telehealth During COVID-19 Does Not
Exacerbate Disparities in Care,'' Health Affairs Blog, May 8, 2020.
DOI: 10.1377/hblog20200505.591306.
Nearly 160 million individuals live in a mental health professional
shortage area, and many more have mental health professionals in their
area that do not accept the patient's insurance or require unfeasible
cost sharing.\16\ Nearly 99 million individuals live in a primary care
health professional shortage area and would be unable or challenged to
receive MOUD without telehealth and audio-only visits.\17\ This
difficulty in access to care for patients is compounded by
transportation, time, and childcare challenges, as well as trauma and
stigmatization from past experiences with the health care system. All
of which makes virtual visits critically important for initiating and
maintaining OUD treatment.
---------------------------------------------------------------------------
\16\ Bureau of Health Workforce, Health Resources and Services
Administration (HRSA), U.S. Department of Health & Human Services,
Designated Health Professional Shortage Areas Statistics: Designated
HPSA Quarterly Summary, as of September 30, 2022 available at https://
data.hrsa.gov/topics/healthworkforce/shortage-areas.
\17\ Ibid.
---------------------------------------------------------------------------
Coverage of and Payment for Audio-Only Services
Telehealth can be a lifeline for many rural residents, who may
encounter significant barriers such as distance, financial, insurance
coverage, or lack of transportation to easily access in-person care.
However, existing barriers continue to hinder the ability for
individuals in rural communities to access quality telehealth services,
as well. The lack of modern broadband infrastructure has proven to be a
primary barrier to equitable telehealth and digital health access for
rural Americans, who are ten times more likely to lack broadband access
than their urban counterparts, leading to fewer audio/video visits.\18\
---------------------------------------------------------------------------
\18\ Kelly A Hirko, Jean M Kerver, Sabrina Ford, Chelsea
Szafranski, John Beckett, Chris Kitchen, Andrea L Wendling, Telehealth
in response to the COVID-19 pandemic: Implications for rural health
disparities, Journal of the American Medical Informatics Association,
Volume 27, Issue 11, November 2020, Pages 1816-1818, https://doi.org/
10.1093/jamia/ocaa156.
In many instances, family physicians have reported that some of their
patients, particularly seniors, are most comfortable with or can only
access audio-only telehealth visits. One recent study of Federally
Qualified Health Centers (FQHCs) found that, by mid-2022, one in five
primary care visits and two in five behavioral health visits were
audio-only, and audio-only visits were still more common than video
visits.\19\ Therefore, permanent telehealth policies must include
coverage of and proper payment for audio-only telehealth services
across programs.
---------------------------------------------------------------------------
\19\ Uscher-Pines, L., McCullough, C.M., Sousa, J.L., et al.
Changes in In-Person, Audio-Only, and Video Visits in California's
Federally Qualified Health Centers, 2019-2022. JAMA. 2023;329(14):1219-
1221. doi:10.1001/jama.2023.1307.
Adequate payment for audio-only telehealth services helps facilitate
equal access to care for rural and underserved communities and enables
patients and physicians to select the most appropriate modality of care
for each visit. Physicians should be appropriately compensated for the
level of work required for an encounter, regardless of the modality or
location. The cognitive work does not differ between in-person and
telemedicine visits. Policies should be geared at providing more tools,
not less, to primary care physicians so they can provide the familiar
and quality care their patients seek. Congress should implement
policies that strengthen patients' relationships with their primary
care physician, and physicians should not be paid less for providing
patient-centered care. Payment should reflect the equal level of
physician work across modalities while also accounting for the unique
---------------------------------------------------------------------------
costs associated with integrating telehealth into physician practices.
To that end, the AAFP strongly urges Congress to pass the Protecting
Rural Health Access Act (S. 1636/H.R. 3440), which would ensure rural
and underserved community physicians can permanently offer telehealth
services, including audio-only telehealth services, and provide payment
parity for these services. The available data clearly indicates that
coverage of and fair payment for audio-only services is essential to
facilitating equitable access to care after the PHE-related telehealth
flexibilities expire. This legislation would also permanently remove
the current section 1834(m) geographic and originating site
restrictions to ensure that all Medicare beneficiaries can access
telehealth services at home, which--as noted above--the AAFP has
supported.
Thank you again for your continued bipartisan leadership to promote and
protect access to high-quality care across modalities, and the AAFP
looks forward to working with you and your colleagues to advance
permanent solutions. Should you have any questions, please contact Anna
Waldman, Associate of Legislative Affairs at [email protected].
Sincerely,
Tochi Iroku-Malize, M.D., MPH, MBA, FAAFP
Board Chair
Founded in 1947, the AAFP represents 129,600 physicians and medical
students nationwide. It is the largest medical society devoted solely
to primary care. Family physicians conduct approximately one in five
office visits--that's 192 million visits annually or 48 percent more
than the next most visited medical specialty. Today, family physicians
provide more care for America's underserved and rural populations than
any other medical specialty. Family medicine's cornerstone is an
ongoing, personal patient-physician relationship focused on integrated
care. To learn more about the specialty of family medicine and the
AAFP's positions on issues and clinical care, visit www.aafp.org. For
information about health care, health conditions and wellness, please
visit the AAFP's consumer website, www.familydoctor.org.
______
American Council on Education et al.
One Dupont Circle, NW
Washington, DC 20036
202-939-9300
https://www.acenet.edu/pages/default.aspx
On behalf of the American Council on Education and the higher education
associations listed below, which represent approximately 4,300 public
and private nonprofit colleges and universities, we thank you for the
opportunity to share our views on telehealth in the higher education
context as part of the record of the Subcommittee on Health Care
hearing on November 14, 2023. This statement highlights the continuing
importance and need for the interstate provision of telemental health
services for students enrolled in an institution of higher education as
a tool to help address the current student mental health crisis.
The mental health of college and university students continues to be an
enormous challenge on campuses across the country, a problem that was
only exacerbated by the COVID-19 pandemic. College students are
reporting mental health challenges at a growing and alarming rate.\1\
Nearly half of students have screened positive for depression, a
significant jump from recent years and a level that disproportionately
impacts marginalized communities.\2\ Many traditional college-aged
students arrive on campus already struggling with mental health
challenges. A recent Centers for Disease Control and Prevention report
found that more than 44 percent of high school students reported that
they struggle with persistent feelings of sadness or hopelessness.\3\
---------------------------------------------------------------------------
\1\ https://www.acenet.edu/Documents/What-Works-Mental-Health.pdf.
\2\ https://healthymindsnetwork.org/wp-content/uploads/2023/03/
HMS_national_print-6-1.pdf; https://healthymindsnetwork.org/wp-content/
uploads/2019/04/HMS_national.pdf; https://www.sciencedirect.com/
science/article/abs/pii/S0165032722002774?via%3Dihub.
\3\ https://www.cdc.gov/mmwr/volumes/71/su/pdfs/su7103a1-a5-H.pdf,
pp. 16, 19.
While mental health concerns are impacting communities across the
country,\4\, \5\ college students face a unique set of
obstacles and challenges that can exacerbate their struggles. In
addition to affecting their well-being, the rise in mental health
issues among college students is impacting their success and
completion. According to a recent national survey,\6\ over half of
current college students (55 percent) who have considered leaving
college, often referred to as ``stopping out,'' cite emotional stress
as the primary driver. The same report also found students of color and
students seeking associate degrees are disproportionally considering
stopping out. In addition, nearly three in five students report
experiencing food insecurity, housing insecurity, or homelessness, and
many more report difficulty meeting other basic needs like childcare
and transportation.\7\ Basic needs insecurity is associated with higher
levels of anxiety, stress, and depression.\8\ Colleges and universities
are diligently responding to meet the surging demand for mental health
services, but many lack the resources to sufficiently do so. Over two
out of five (44 percent) college students are struggling with
clinically significant anxiety or depression, but less than half of
these students had mental health counseling and/or therapy in the past
year.\9\
---------------------------------------------------------------------------
\4\ https://www.hhs.gov/sites/default/files/surgeon-general-social-
connection-advisory.pdf.
\5\ https://www.hhs.gov/sites/default/files/surgeon-general-youth-
mental-health-advisory.pdf.
\6\ https://www.gallup.com/analytics/468986/state-of-higher-
education.aspx.
\7\ https://hope.temple.edu/sites/hope/files/media/document/
HopeSurveyReport2021.pdf.
\8\ https://pubmed.ncbi.nlm.nih.gov/35124789/.
\9\ https://healthymindsnetwork.org/wp-content/uploads/2023/03/
HMS_national_print-6-1.pdf.
To help address the college student mental health crisis and the
expiration of COVID-19 era waivers, Congress should authorize the
interstate provision of telehealth services for students enrolled in an
institution of higher education in any U.S. jurisdiction if that
healthcare provider is licensed to practice or provide such care in any
---------------------------------------------------------------------------
one state or territory or through an interstate licensure compact.
During the pandemic, nearly every state instituted an emergency waiver
to facilitate interstate care. Institutions relied on those waivers to
use telehealth to continue to provide needed mental health services to
students who were away from campus and unable to access campus
counseling services. Unfortunately, these waivers are now expired,
leaving many college students without access to medically necessary
behavioral health care. Telehealth access to campus mental health
services remains a critical need for students seeking treatment for
depression, anxiety, and other mental health conditions.
Many students encounter disruption in behavioral health treatment when
they leave campus during breaks, participate in remote educational
programs, or need to find a new behavioral healthcare provider due to
licensing restrictions preventing clinicians from practicing across
state lines. These can also serve as barriers to students accessing
care. While state-by-state compacts represent a positive development,
they do not answer this national need.
Permitting colleges and universities to provide interstate telemental
health services would address a unique challenge faced by students
experiencing a behavioral health crisis and may also improve retention
and graduation rates among affected students. Importantly, this
flexibility would also help ensure continuity of care for students who
have established therapeutic relationships with campus mental health
providers or with healthcare providers in their home state during the
course of their education.
We thank the Subcommittee for the opportunity to submit these comments
and for considering our views.
Sincerely,
Ted Mitchell
President
On behalf of:
American Association of Community Colleges
American Association of State Colleges and Universities
American Council on Education
Association of American Universities
Association of Catholic Colleges and Universities
Association of Jesuit Colleges and Universities
Association of Public and Land-grant Universities
College and University Professional Association for Human Resources
Council for Christian Colleges & Universities
National Association of College and University Business Officers
National Association of Independent Colleges and Universities
State Higher Education Executive Officers Association
______
American Occupational Therapy Association
6116 Executive Boulevard, Suite 200
North Bethesda, MD 20852-4929
301-652-6611
https://www.aota.org/
The American Occupational Therapy Association (AOTA) is the national
professional association representing the interests of more than
230,000 occupational therapists, occupational therapy assistants, and
students of occupational therapy. The science-driven, evidence-based
practice of occupational therapy enables people of all ages to live
life to its fullest by promoting participation in daily occupations or
activities. In so doing, growth, development, and overall functional
abilities are enhanced, and the effects associated with illness,
injuries, and disability are minimized.
Occupational Therapy via Telehealth History
The vast majority of occupational therapy professionals (OTPs) did not
utilize telehealth to provide occupational therapy (OT) services before
the COVID-19 pandemic since Congress had not previously established
OTPs as Medicare telehealth providers. Significant innovation, however,
was occurring at the Veterans Administration where OTPs were providing
innovative OT services to patients, so the template for OT via
telehealth was already developed. The number of OT telehealth
encounters increased dramatically as Congress and CMS reacted quickly
to enable Medicare beneficiaries to receive OT and other therapy
services via telehealth once a Public Health Emergency (PHE) was
declared.
Congressional action was essential to waive statutory restrictions on
CMS that prevented OTPs as well as physical therapists (PTs) and speech
language pathologists (SLPs) from providing services via telehealth in
Medicare. CMS responded to Congressional waivers included in the CARES
Act by issuing an emergency rule that added a series of therapy
CPT' codes to the telehealth services list and another rule
that included OTPs as eligible Medicare telehealth providers. This
effectively enabled OTPs to provide services via telehealth to Part B
Medicare beneficiaries during the COVID-19 emergency. Congress acted
again in 2022 to extend these waivers through the end of 2024, and this
allowed OT via telehealth to continue after the PHE expired on May 11,
2023. Further Congressional action, however, is necessary to allow such
services to continue in Medicare on a permanent basis.
While Congressional language and intent was clear in the Omnibus Budget
Act of 2023 that OTPs were to continue as telehealth providers at least
until the end of 2024, CMS misinterpreted this provision as not
applying to OT services provided via telehealth in certain facility-
based settings including outpatient rehab facilities. This decision
trickled out to these facilities in April 2023 with the PHE ending
within a few weeks. After significant confusion imposed on facilities
and engagement by multiple stakeholders including AOTA, CMS clarified
that OTPs in all settings were covered by the Congressional waiver, and
then extended this policy in its 2024 Fee Schedule. For this reason,
AOTA urges Congress to proactively list OTPs along with PTs and SLPs as
permanent Medicare telehealth providers as it did for all other
Medicare telehealth providers in the past.
Legislation such as the CONNECT for Health Act of 2023 (S, 2016) would
give CMS the authority to determine the telehealth status of OTPs and
other therapists which is a step in the right direction; however, after
the confusion related to OT in various settings, we urge Congress to
make this determination by enacting the Expanded Telehealth Access Act
(S. 2880/H.R. 3875). S. 2880 was introduced by Senators Steve Daines
and Tina Smith to specifically enable OTPs, PTs, SLPs and audiologists
to provide services via telehealth under Section 1834(m) of the Social
Security Act on a permanent basis.
Experience Demonstrates Effectiveness of OT Services via Telehealth
The rapid expansion of telehealth as a delivery mechanism for OT
services during and after the PHE enabled occupational therapists and
occupational therapy assistants to demonstrate the clear value of these
services provided alone or in conjunction with in-person services.
Telehealth has been especially beneficial for people in rural and other
underserved areas and to those for whom travel to receive services was
already a barrier to access, including people with disabilities.
Virtual home safety evaluations have emerged as an additive OT
telehealth benefit that cannot be duplicated in a facility/office
setting. OTPs report that telehealth has enabled in-home ``video
tours'' to identify home safety issues that would never be identified
by the patient in a facility/office setting. This can be crucial in
preventing falls, addressing functional decline, and avoiding costly
emergency room visits and hospital admissions which can reduce the cost
of care. This service would end altogether if Congress does not allow
OTPs to continue as Medicare telehealth providers after waivers end in
2024.
The ability to provide OT services via telehealth has also enabled more
patients to start care on the day ordered and to minimize
cancellations, postponements, and schedule changes that are commonly
connected to transportation, mobility, caregiver availability, weather,
and other issues related to treatment in a clinical setting. This in
turn has enabled some patients to complete treatment sooner and with
fewer visits, which can reduce the cost of care.
In addition, telehealth has also made it much easier to connect with
beneficiary caregivers who are often unable to take the time required
to travel with the patient to in-person visits. This is especially
important for some patients in the Medicare population who rely more
heavily on a caregiver for assistance during appointments and for
follow-up in the home.
Research Demonstrates Efficacy of OT Delivered via Telehealth
The AOTA Telehealth Position Paper \1\ summarizes how occupational
therapy practitioners use telehealth technologies as a method for
service delivery for evaluation, intervention, consultation,
monitoring, and supervision of students and other personnel. Further,
it references the results of research on the use of telehealth in
rehabilitation or habilitation, which includes occupational therapy.
---------------------------------------------------------------------------
\1\ American Occupational Therapy Association (2013). Telehealth.
American Journal of Occupational Therapy, 67(6 Suppl.), S69-S90. http:/
/dx.doi.org/10.5014/ajot.2013.67S69.
There is a growing base of evidence demonstrating the efficacy of
technologically mediated occupational therapy.\2\ Ongoing research at
University of Southern California Mrs. T. H. Chan Division of
Occupational Science and Occupational Therapy Faculty Practice has
shown that increased use of telehealth for pain-management patients
decreased cancellations, increased access, and improved treatment
effectiveness. Patient satisfaction with telehealth is also high. A
more detailed list of their findings follows:
---------------------------------------------------------------------------
\2\ Cason, J. (2009). A Pilot Telerehabilitation Program:
Delivering Early Intervention Services to Rural Families. International
Journal of Telerehabilitation, 2009;1(1):29-37. Hoffmann, T., Russell,
T., Thompson, L., Vincent, A., Nelson, M. (2008). Using the Internet to
assess activities of daily living and hand function in people with
Parkinson's disease. NeuroRehabilitation, 23, 253-261. Ng, E.M.,
Polatajko, H.J., Marziali, E., Hunt, A., Dawson, D.R. (2013).
Telerehabilitation for addressing executive dysfunction after traumatic
brain injury. Brain Inj. 2013; 27(5):548-64.
Improved treatment effectiveness due to improved ability to
assess and evaluate a person's home environment and contextual factors,
rather than through verbal discussion or photos. This allows for more
effective problem solving and identification of environmental barriers.
This is especially clear in OT interventions for pain regarding body
mechanics, ergonomics, physical activity routines, sleep positioning,
falls prevention and recovery, and placement of durable medical
---------------------------------------------------------------------------
equipment for optimal safety.
Ability to access more people with chronic pain by eliminating
the geographic barrier of having to drive to an in-person session. A
recent evaluation of a telehealth group intervention for pain
management, specifically for patients living in rural or remote areas,
revealed that participants benefited from telehealth specialty pain
management services.\3\
---------------------------------------------------------------------------
\3\ Scriven, H., Doherty, D.P., & Ward, E.C. (2019). Evaluation of
a multisite telehealth group model for persistent pain management for
rural/remote participants. Rural & Remote Health, 19(1).
Decreased cancellation rates due to pain flare ups or symptom
exacerbations because patients do not have to commute to in-person
sessions, but can participate from the comfort of their own home where
they can access many of their pain management tools (i.e., medication,
heat/ice, self-massage units, lying down as needed, more control over
---------------------------------------------------------------------------
ambient temperature).
Improved continuity of care because patients who would travel
long distances to come to the clinic may only be seen for treatment 1x/
month, but with telehealth services, they can be seen weekly for
improved accountability and to support long-term, sustainable behavior
change.
Improved patient satisfaction--patients are reporting improved
participation and effectiveness of treatment because commuting to the
clinic and driving can often be a trigger of pain or stress. By
eliminating this factor, patients avoid starting treatment sessions in
pain or fatigue and are able to participate more effectively during
session.
Reduced social isolation and occupational deprivation--due to
compounding factors of managing a chronic condition and the long-term
effects of pandemic-
related restrictions, patients are reporting feelings of isolation and
reduced functional participation in daily routines and meaningful
activities. Experiencing occupational deprivation can have detrimental
effects on health and wellness, self-efficacy, and identity.\4\ With OT
telehealth, patients can collaborate with their OT to identify
strategies and opportunities to engage in occupations and social
activities to combat isolation, occupational deprivation, and
associated adverse health consequences.
---------------------------------------------------------------------------
\4\ Whiteford, G. (2000). Occupational deprivation: global
challenge in the new millennium. British Journal of Occupational
Therapy, 63(5).
Additional research has shown strong strength of evidence that
motivational interviewing, fatigue management, and medication adherence
---------------------------------------------------------------------------
performed via telehealth lead to positive outcomes.
Based on this research, both Medicare beneficiaries and the Medicare
program would see great benefits in quality care, reduced costs, and
reduced hospitalizations if occupational therapy is utilized fully.
AOTA asserts that the same ethical and professional standards that
apply to the traditional delivery of occupational therapy services also
apply to the delivery of services received via telehealth. Occupational
therapy interventions delivered via telehealth can assist patients to
regain, develop, and build functional independence in everyday life
activities to significantly enhance a Medicare beneficiary's quality of
life. Telehealth may also address provider shortages and access
problems, making necessary occupational therapy services available to
underserved beneficiaries in remote, inaccessible, or rural settings
and to beneficiaries with limited mobility outside their home. Further,
occupational therapy is the chief profession with expertise in
activities of daily living and community environments, which may be
better observed and evaluated through telehealth services when the
beneficiary is in their home environment.
Occupational Therapists Describe Benefits of OT via Telehealth
AOTA is confident that ongoing research and analysis by CMS and others
into the use of telehealth to provide OT services will demonstrate what
we are already hearing from OTPs throughout the country. Some examples
of the use of telehealth to provide OT services follow:
One particular patient was a woman with Parkinson's. She and her
husband were sleeping on an air mattress in their den because she had a
hip fracture and was not steady enough to climb the stairs to her
bedroom. After her OT eval, she refused further in-person visits. I
trialed telehealth visits with great success. I was able to have the
husband aim the camera so that I was able to provide placement of
recommended grab bars in the bathrooms, both upper and lower levels, as
well as get a tour of the second level, something I had not been able
to assess at the eval. I was able to help with technique and
positioning for upper extremity exercises, and eventually, I was able
to teach the husband how to assist the patient up/down the stairs,
safely, as well as teach bed mobility so that the patient was able to
sleep in her own bed upstairs versus an air mattress on the floor on
the main level. She and her husband looked forward to my weekly visits
and always updated me on the progress she had made. They were so
grateful for the therapy I was able to provide remotely.
Telehealth has been crucial for service to our CMS patients in
our Post-ICU multidisciplinary clinic. Many of these patients would not
be able to access the services for a variety of reasons if we cannot
continue with telehealth.
Telemedicine has been a very helpful but unexpected resource for
service delivery. One of the primary barriers to clients participating
in the 55+ Program in the past has been transportation. Many clients
are fearful of driving, unable to drive due to other health conditions,
or do not have access to a vehicle and alternative transportation is
too expensive. Telemedicine has allowed these clients access to
treatment now.
Initially many of my older adult clients struggled and were
fearful of technology and did not think they would be able to
participate in online treatment. With coaching and assistance, many
clients have overcome these barriers and now are using technology more
to connect with family, friends, and other community resources. It has
helped to decrease isolation for many both for treatment and in the
community.
I am an occupational therapist in an outpatient neurological
clinic. The majority of my patient caseload includes adults and older
adults with comorbidities and/or [who] are immuno-compromised. During
the global pandemic, taking months off of therapy could have resulted
in significant decrease in function for some of the patients I serve.
Our clinic was on the edge of our seats while waiting to hear the CMS
changes to allow occupational therapy providers to provide telehealth
services. Once the change had been made, it opened up a new world of
opportunity for us to serve these patients who so needed skilled
therapy, but were unable to physically come into the clinic. As
occupational therapists, we adapt. I am able to provide individualized,
client-centered care through a new medium that was aligned with the
patient's plan of care to reach their functional goals. Without the
ability to provide the skilled services via telehealth, our clients
would not have received the care they needed. Patients have been
surprised with the effectiveness of telehealth therapy services. If CMS
allows these changes to be permanent, we would be able to better serve
those patients in effective ways through the use of this technology.
Global Telehealth Issues of Specific Concern to AOTA
While Congressional action is urgently needed now to allow occupational
therapy professionals to provide services via telehealth on a permanent
basis, AOTA also notes that for telehealth to move forward in any way,
several other issues must also be addressed. In order to maximize the
benefit of telehealth services, the originating site for a telehealth
visit must be the patient's home, especially for OT services as
described above. In addition, there is no justification for a payment
differential for telehealth services, as practice expenses are unlikely
to go down since practitioners need to maintain an office to perform
both telehealth and in-person visits. Additionally, practice expense
may increase as practitioners invest in HIPAA-compliant software and
other technology to assist in telehealth visits. Also, Congress must
allow some limited services to be provided via audio only, especially
in the area of mental health and substance abuse, with self-care as an
example of a code used by OT professionals.
Summary--Congressional Action Essential
to Avoid Therapy Telehealth Cliff
In summary, OT interventions delivered via telehealth have enabled
patients to develop, regain, and build functional independence in
everyday life. Telehealth has also demonstrated advantages over in-
person visits in some situations, especially for people in rural and
underserved areas, and for the large number of seniors in all
communities who face transportation and mobility issues, especially
those with disabilities. Telehealth is also an ideal platform for
conducting home safety evaluations as it provides a window into the
person's home and often greater access to their caregiver.
As noted, Congressional action is essential to enable Medicare
beneficiaries to continue to receive OT services via telehealth when
appropriate. Passage of the Expanded Telehealth Access Act (S. 2880)
would enable OT professionals as well as PTs, SLPs, and audiologists to
provide services via telehealth under Section 1834(m) of the Social
Security Act. Unless Congress acts, Medicare beneficiaries will face a
telehealth ``cliff'' on December 31, 2024, whereby beneficiaries who
are now accustomed to receiving some OT services via telehealth
suddenly lose access to such services. We urge Congress to prevent this
outcome.
______
American Physical Therapy Association
3030 Potomac Ave., Suite 100
Alexandria, VA 22305
703-684-2782
https://www.apta.org/
On behalf of our more than 100,000 member physical therapists, physical
therapist assistants, and students of physical therapy, the American
Physical Therapy Association submits the following comments in response
to the Senate Finance Committee hearing ``Ensuring Medicare Beneficiary
Access: A Path to Telehealth Permanency.'' APTA is dedicated to
building a community that advances the physical therapy profession to
improve the health of society. As experts in rehabilitation,
prehabilitation, and habilitation, physical therapists play a unique
role in society in prevention, wellness, fitness, health promotion, and
management of disease and disability for individuals across the age
span, helping individuals improve overall health and prevent the need
for avoidable health care services. Physical therapists' roles include
education, direct intervention, research, advocacy, and collaborative
consultation. These roles are essential to the profession's vision of
transforming society by optimizing movement to improve the human
experience.``The Economic Value of Physical Therapy in the United
States,''\1\ a recently released APTA report, showcases the cost-
effectiveness and economic value of physical therapist services for a
broad range of common conditions. The report compares physical therapy
with alternative care across a suite of health conditions commonly seen
within the U.S. health care system. The report underscores and
reinforces the importance of including physical therapists and physical
therapist assistants as part of multidisciplinary teams focused on
improving patient outcomes and decreasing downstream costs. The
committee should consider the insights provided in this report \2\ to
support access to, coverage of, and payment for physical therapist
services, and to support policies that position physical therapists as
entry-point providers to ensure beneficiaries have timely access to
proven, cost-effective care.
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\1\ https://www.valueofpt.com/.
\2\ https://www.valueofpt.com/policy-and-payment/for-policymakers.
As noted in APTA's recent economic report,\3\ physical therapy can
clearly decrease health care costs and reduce administrative burdens.
As digital health technologies, including telehealth, expand into the
health sector, physical therapists' and physical therapist assistants'
access to these delivery tools should be considered in decisions
regarding payment, coverage, broadband, and technology infrastructure
policies. For example, the APTA report \4\ demonstrates that physical
therapy-based cancer telerehabilitation programs deliver a net cost
benefit of approximately $4,000 per episode of care.
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\3\ https://www.valueofpt.com/globalassets/value-of-pt/
economic_value_pt_u.s._report_from_
apta-policy_paper-policymakers.pdf.
\4\ https://www.valueofpt.com/.
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Expansion of Telehealth Under Medicare Due to the COVID-19 Pandemic
In response to the coronavirus public health emergency in 2020,
Congress passed and the president signed into law legislation that
authorized the Centers for Medicare & Medicaid Services to
significantly expand Medicare's coverage of telehealth services during
the PHE to protect the health and safety of Medicare patients. Under
the authority of Section 1135 of the Social Security Act, CMS permitted
virtually all medical providers, including physical therapists, to
provide services via telehealth to Medicare beneficiaries. In late
2022, Congress approved legislation that extended Medicare's telehealth
flexibilities for another two years. Therapy providers will be
permitted to provide services to Medicare beneficiaries via telehealth
until December 31, 2024. After that date, Medicare patients will lose
telehealth as an option unless Congress acts.
The Role of Telehealth as an Option for the Delivery of Therapy Services
Physical therapists and physical therapist assistants use telehealth as
a supplement to in-person services to treat a variety of conditions
prevalent in the Medicare population, including but not limited to
arthritis, multiple sclerosis, musculoskeletal conditions, Parkinson's
disease, pelvic floor dysfunction, frailty, sarcopenia, and cognitive,
neurological, and vestibular disorders. Physical therapists make
determinations, in consultation with patients and caregivers, regarding
the appropriate mix of in-person and telehealth services to meet the
goals in the plan of care. The evaluation and treatment of a patient
via the use of telehealth allows the physical therapist to interact
with the patient within the real-life context of their home
environment, which is not easily replicable in the clinic. Patient and
caregiver self-efficacy are inherent goals of care, and telehealth not
only allows a physical therapist to maintain the continuity of care
anticipated in the plan of care, but also allows for immediate and
effective engagement when a specific challenge arises.
Skilled physical therapist interventions delivered through an
electronic or digital medium have the potential to prevent falls,
functional decline, costly emergency room visits, and hospital
admissions and readmissions. Further, physical therapists already are
experienced in modifying exercises for the patient to perform them
safely at home, as a home exercise program is a common element of a
treatment plan for patients who are treated in person. Physical therapy
practitioners can use telehealth technologies to deliver the following
services:
Conduct evaluations or reevaluations, or provide quicker
screening, assessment, and referrals that improve care coordination.
Provide interventions via telehealth by interacting with the
patient in real time to provide instruction in exercise and activity
performance, observe return demonstration, offer instruction in
modifications or progressions of a program, provide caregiver support,
and promote self-efficacy.
Give verbal and visual instructions and cues to modify how
patients perform various activities. They also may suggest that the
patient or caregiver modify the environment for safety reasons or to
produce even more optimal outcomes.
Conduct home safety evaluations and provide prehabilitation.
Observe how patients interact with their environment and/or
other caregivers, and to provide caregiver education.
Determine the effectiveness of modifications to activities and
strategies immediately rather than waiting for the next in-person
visit.
Reduce the number of in-clinic visits and still maintain
important follow-up care. This might reduce travel time and/or burden
for a patient, which, for some conditions, might result in faster
healing. This also prevents any delays in modifying a program when it
needs to be upgraded or downgraded.
Co-treat with another clinician who is treating via real-time
audio and visual technology.
Consult directly with another PT or PTA for collaboration or to
obtain specialty recommendations to incorporate into an existing plan
of care.
Conduct quick check-ins with established patients.
Policy Recommendation
APTA supports the ability of Medicare beneficiaries to maintain the
option--when appropriate--to have therapy services provided via
telehealth. The expansion of Medicare telehealth policies under the
Section 1135 waivers, including permitting physical therapist services
to be furnished via telehealth by PTs and PTAs, has provided greater
options for patients to access care, especially in rural and
underserved areas. APTA strongly urges Congress to enact legislation to
maintain the current policy and add physical therapists and physical
therapist assistants as permanently authorized telehealth providers
under Medicare. Congress should enact the bipartisan Expanded
Telehealth Access of Act of 2023 (H.R. 3875/S. 2880) \5\ before the
expiration of the current waiver on December 31, 2024.
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\5\ https://www.apta.org/advocacy/issues/telehealth/expanded-
telehealth-access-act.
We appreciate the opportunity to share our perspective on the role of
telehealth in physical therapy and the need to continue to provide
Medicare beneficiaries this option beyond the PHE by ensuring that PTs
and PTAs become permanent authorized telehealth providers. Again, APTA
strongly supports enactment of the Expanded Telehealth Access Act (H.R.
3875/S. 2880) to accomplish this goal. Should you have any questions,
please contact APTA Congressional Affairs Specialist Steve Kline at
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[email protected]. Thank you for your time and consideration.
______
American Society of Health-System Pharmacists
4500 East-West Highway, Suite 900
Bethesda, MD 20814
301-657-3000
https://www.ashp.org/
November 14, 2023
The Honorable Benjamin L. Cardin
Chairman
Senate Finance Committee Subcommittee on Health Care
United States Senate
219 Dirksen Senate Office Building
Washington, DC 20510-6200
The Honorable Steve Daines
Ranking Member
Senate Finance Committee Subcommittee on Health Care
United States Senate
219 Dirksen Senate Office Building
Washington, DC 20510-6200
Re: Ensuring Medicare Beneficiary Access: A Path to Telehealth
Permanency.
Dear Chairman Cardin and Ranking Member Daines:
We applaud the Senate Finance Committee, Subcommittee on Health Care,
for examining whether to make permanent the telehealth authorities that
were critical for providing Medicare beneficiaries access to care
during the COVID-19 public health emergency (PHE).
ASHP is the largest association of pharmacy professionals in the United
States, representing over 60,000 pharmacists, student pharmacists, and
pharmacy technicians in all patient care settings, including hospitals,
ambulatory clinics, and health-
system community pharmacies. We recommend that telehealth flexibilities
be made permanent.
Telehealth authorities enabled ASHP's members to provide critical
pharmacy services to Medicare beneficiaries throughout the COVID-19
public health emergency (PHE). Continuation of these authorities will
expand access to care in rural and urban medically underserved areas,
as well as provide critical care to those suffering from chronic
conditions like substance use disorders (SUD). The success of
telehealth services during the PHE has illustrated the value of
telehealth long-term, particularly for patients with mobility issues.
Virtual Supervision: The Centers for Medicare and Medicaid Services
(CMS) allowed virtual supervision during the PHE and has extended this
authority through 2024, but has yet to make it permanent. Virtual
supervision has allowed physicians and pharmacists to provide services
from separate locations, as part of the same care team. This model
increased patient access to care, particularly in rural and urban
underserved areas, and also allowed for separation of providers during
periods of high viral spread, which will continue to be an issue even
in the post-PHE environment. These flexibilities were extended until
the end of 2024. AHSP recommends that virtual supervision be extended
permanently.
Initiation of Controlled Substance Prescribing: In 2021, more than 46
million U.S. patients met the criteria for substance use disorder.\1\
During the PHE, the Drug Enforcement Administration (DEA) permitted
DEA-registered clinicians to prescribe schedule II-V controlled
substances, including buprenrophine for substance use disorder (SUD),
to patients without an in-person medical evaluation, provided a
telehealth visit is conducted and other conditions are met. This
authority is set conclude on December 31, 2024 and DEA has indicated
they are still considering potential limits on telehealth prescribing
of controlled substances, including buprenorphine. Congress passed the
Mainstreaming Addiction Treatment Act, because it recognized the need
to expand access to medications for opioid use disorder (MOUDs).
Continuation of the use of telehealth to prescribe medications for
opioid used disorder, like buprenorphine, is another essential step to
maintain and expand access to MOUDs. ASHP recommends allowing the
prescribing of schedule II-V controlled substances to patients via a
telehealth visit be made permanent.
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\1\ Substance Abuse and Mental Health Services Administration. Key
Substance Use and Mental Health Indicators in the United States; 2023.
DEA Definition Undermines Delivery of Medication Management via
Telehealth: The DEA defines telemedicine at 21 U.S.C. Sec. 802(54) as
follows: ``The term `practice of telemedicine' means, for purposes of
this title, the practice of medicine in accordance with applicable
Federal and State laws by a practitioner (other than a pharmacist) who
is at a location remote from the patient and is communicating with the
patient, or health care professional who is treating the patient. . .
.'' This definition is based on outdated understanding of clinical and
ambulatory pharmacy practice, and will significantly impede patient
access to services. Eleven states now recognize pharmacists as
prescribers of controlled substances, including buprenorphine.\2\
Congress should not allow antiquated DEA rules to undermine patient
access to pharmacist medication management services via telehealth.
ASHP recommends elimination of the pharmacist exclusion from the DEA's
definition of ``practice of telemedicine.''
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\2\ CA, ID, MA, MT, NV, NM, NC, OH, UT, TN, and WA.
Incident-to Billing of Evaluation and Management Services: To ensure
the long-term success of telehealth, greater clarity is needed
regarding billing codes. Currently, CMS has unnecessarily limited
physicians' ability to bill fully for evaluation and management (E/M)
services provided by a pharmacist on their care team, incident to the
physician. According to a 2018 CMS clarification, incident-to services
provided by a pharmacist \3\ cannot be billed at anything beyond the
lowest level of E/M codes, regardless of the complexity of care or the
duration of the service (e.g., 99211 in person or 99441 for
telehealth). Use of the E/M codes for billing of telehealth services is
also confusing and inconsistent. In order for it to be financially
feasible for care teams to use their pharmacists to provide medication
and chronic disease services through telehealth, ASHP recommends that
physicians be allowed to bill for E/M codes for established patients
(99211-99215) and telehealth codes (telephonic equivalent to E/M codes)
(99441-99443), including when provided by a pharmacist, if the
incident-to requirements are met.
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\3\ Note that as members of the healthcare team, clinical
pharmacists practice under formally granted clinical privileges from
the medical staff or credentialing system of the organization in which
they practice or under written collaborative practice agreements (CPA)
with individual physicians or medical groups. The Centers for Disease
Control and Prevention has found ``strong evidence that when
pharmacists are part of the health care team, outcomes related to
preventing or managing chronic diseases and adherence to medication
improve.'' These outcomes include clinical and behavioral health
indicators including lowering blood pressure, HbA1c, and LDL
cholesterol levels (CDC Advancing Team Based Care).
Licensure: As recognized in the Better Mental Health Care, Lower-Cost
Drugs, and Extenders Act, clarity regarding licensure around telehealth
is critical to expanding access to beneficiary care for beneficiaries
suffering from such conditions as mental health and SUD. To ensure
access and continuity of care, states have been adopting a number of
multi-jurisdictional flexibilities. These arrangements permit providers
in another jurisdiction to use telehealth to treat a patient in another
state. CMS needs to clearly indicate that telehealth services provided
under these arrangements will be covered under Medicare and Medicaid.
ASHP recommends that these multi-jurisdictional licensure flexibilities
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be recognized by Medicare.
ASHP thanks you for your work on telehealth. We look forward to
continuing to work with you on this issue. If you have questions or if
ASHP can assist in any way, please contact Frank Kolb at
[email protected].
Sincerely,
Tom Kraus
Vice President, Government Relations
Cc: The Honorable Finance Committee Chairman Ron Wyden and The
Honorable Ranking Member Mike Crapo.
______
American Urological Association
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 410-689-3700
Fax: 410-689-3800
https://www.auanet.org/
November 27, 2023
The Honorable Ron Wyden
Chair
Senate Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
The Honorable Mike Crapo
Ranking Member
Senate Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
Re: Statement for the Record, Hearing on Ensuring Medicare Beneficiary
Access: A Path to Telehealth Permanency
Dear Chair Wyden and Ranking Member Crapo:
The American Urological Association (AUA) applauds the Senate Committee
on Finance for holding the recent legislative hearing, Ensuring
Medicare Beneficiary Access: A Path to Telehealth Permanency. We
commend the Committee for examining policies to improve Medicare
beneficiary access to care through telehealth.
The AUA is a globally engaged organization with more than 22,000
physicians, physician assistants, and advanced practice nursing members
practicing in more than 100 countries. Our members represent the
world's largest collection of expertise and insight into the treatment
of urologic disease. Of the total AUA membership, more than 15,000 are
based in the United States and provide invaluable support to the
urologic community by fostering the highest standards of urologic care
through education, research, and the formulation of health policy.
The AUA has prioritized telehealth since expanded access substantially
benefits our members' patients and has formed a Urology Telehealth Task
Force (UTTF) comprised of experts in this area. We have been actively
engaged on telehealth policy and provided comments on the Centers for
Medicare & Medicaid Services (CMS) regulations and draft legislation,
including the Creating Opportunities Now for Necessary and Effective
Care Technologies (CONNECT) for Health Act of 2023 (Pub. L. 117-328),
on the topic. The AUA stands ready to work with you to develop
permanent Medicare policies and appreciates your consideration of the
following comments as you consider future legislation on this topic.
Lessons Learned
Since the beginning of the COVID-19 pandemic and the implementation of
Medicare telehealth flexibilities, urologists have transformed their
practices to deliver high-quality care to patients via telehealth. Data
since the beginning of the COVID-19 pandemic has shown the impact of
telehealth on cost, quality, and access to care and the results are
clear--telehealth has not led to excessive healthcare utilization and
spending, does not compromise quality of care for patients, and
improves access to care for patients.
Utilization and Costs
From July 2021 through December 2022, the proportion of telehealth-
based evaluation and management visits among Medicare fee-for-service
beneficiaries maintained consistently around 11%, and from March 2020
through December 2022, the combined total number of monthly in-person
and telehealth office visits did not exceed 2019 utilization levels at
any point (Figure 1, Ellimoottil 2023).\1\
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\1\ Ellimoottil et al. Analysis of Medicare FFS data. 2023.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Additionally, the availability of telehealth has not led to
additional primary care visits, refuting the concern about unnecessary
utilization.\2\ On the contrary, it has promoted more timely access to
healthcare services, especially for individuals in remote or
underserved areas, thereby addressing disparities in healthcare access.
This in turn has the potential to reduce our country's health care
spending by minimizing costs for time, travel, and staff and allowing
for timely care and optimized treatments and outcomes.
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\2\ Dixit, R.A., Ratwani, R.M., Bishop, J.A. et al. The impact of
expanded telehealth availability on primary care utilization. npj
Digit. Med. 5, 141 (2022). https://doi.org/10.1038/s41746-022-00685-8.
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Quality
The Agency for Healthcare Research and Quality (AHRQ) conducted a
systematic review of 165 studies reporting quality outcomes as it
relates to telehealth visits. The review concluded, ``Across a variety
of conditions, telehealth produced similar clinical outcomes as
compared with in-person care; differences in clinical outcomes, when
seen, were generally small and not clinically meaningful when comparing
in-person with telehealth care.''\3\ Therefore, the widespread
satisfaction and maintained level of quality highlights the potential
for sustained integration of telehealth services into the U.S.
healthcare system.
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\3\ https://effectivehealthcare.ahrq.gov/sites/default/files/
related_files/use-telehealth-during-COVID-19-systematic-review.pdf.
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Access
There is no doubt that telehealth has great potential to improve access
to care and reduce health inequities and disparities, particularly for
individuals living in rural and underserved areas who are required to
travel significant distances to see specialists, like urologists. The
Medicare Payment Advisory Commission's (MedPAC) 2023 report to Congress
highlighted that greater telehealth use was associated with ``slightly
improved access to care for some beneficiaries.''\4\ Additionally,
based on patient satisfaction ratings, telehealth visits consistently
outperform in-person visits in terms of access and provider concern.\5\
Results also show that individuals who are older, African-American,
require an interpreter, use Medicaid, and live in areas with broadband
challenges are less likely to use video visits as compared to phone
calls.\6\ This clearly highlights the need for coverage and payment for
not only video telehealth services, but audio-only services as well.
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\4\ https://www.medpac.gov/document/june-2023-report-to-the-
congress-medicare-and-the-health-care-delivery-system/.
\5\ Patel, K.B., Alishahi Tabriz, A., Turner, K., Gonzalez, B.D.,
Oswald, L.B., Jim, H.S.L., Nguyen, O.T., Hong, Y.R., Aldawoodi, N.,
Cao, B., Wang, X., Rollison, D.E., Robinson, E.J., Naso, C., Spiess,
P.E. Telemedicine Adoption in an NCI-Designated Cancer Center During
the COVID-19 Pandemic: A Report on Patient Experience of Care. J Natl
Compr Canc Netw. 2023 May;21(5):496-502.e6. doi: 10.6004/
jnccn.2023.7008. PMID: 37156477.
\6\ Chen, J., Li, K.Y., Andino, J., Hill, C.E., Ng, S., Steppe, E.,
Ellimoottil, C. Predictors of Audio-Only Versus Video Telehealth Visits
During the COVID-19 Pandemic. J Gen Intern Med. 2022 Apr;37(5):1138-
1144. doi: 10.1007/s11606-021-07172-y. Epub 2021 Nov 17. PMID:
34791589; PMCID: PMC8597874.
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Legislative Solutions
The AUA appreciates the action Congress has already taken to extend the
waiver of the originating site and geographic restrictions and coverage
of audio-only services through December 31, 2024, in the Consolidated
Appropriations Act, 2023 (Pub. L. 117-328). However, more must be done
to make these policies permanent to protect patient access to
telehealth services.
The AUA supports the CONNECT for Health Act of 2023 that would
permanently expand access to certain telehealth services ensuring that
Medicare beneficiaries can continue to receive virtual care.
Specifically, the bill would remove barriers to telehealth coverage in
the following ways:
Permanently removes geographic requirements for telehealth
services.
Expands originating sites to include the patient's home and
other clinically appropriate sites.
Expands the authority for practitioners eligible to furnish
telehealth services.
Improves Medicare's process to add telehealth services.
Permanently allows Federally Qualified Health Centers and Rural
Health Clinics to furnish telehealth services as distant site
providers.
Removes restrictions for facilities of the Indian Health Service
and Native Hawaiian Health Care.
Repeals the 6-month in-person visit requirement for telemental
health services.
Permanently allows for the waiver of telehealth restrictions
during public health emergencies.
Permanently allows for the use of telehealth in the
recertification of a beneficiary for hospice.
The AUA urges the committee to support these provisions to ensure that
telehealth continues to be accessible to Medicare beneficiaries.
However, we believe Congress must do more to make telehealth policies
permanent to ensure equitable access to telehealth services.
Payment Parity
While telehealth has consistently accounted for approximately 11% of
office visits since July 2021, the AUA is concerned that there will be
a decline in telehealth usage once telehealth flexibilities expire on
December 31, 2024. Before reimbursement was established for telehealth
during the COVID-19 public health emergency, few urologists equipped
their practices with the platforms and infrastructure required to
deliver virtual care. Telehealth platforms have their own associated
costs, and urologists and their practices have limited reserve funds
for technology that does not demonstrate a significant return on
investment. Additionally, telemedicine requires many of the same
overhead costs as in-person visits because the administrative
requirements associated with the visit do not change and clinical space
is still required for the treating physician, which preserves
physician-patient privacy during the encounter, and practices cannot
reduce the amount of clinical space available since virtual care
supplements in-person care and is not a replacement.
The AUA believes that whether payment parity between in-person and
virtual care is maintained will influence whether urologists and other
physicians sustain their telehealth infrastructure and continue to
offer virtual care to patients. We were grateful that CMS finalized
policy to maintain payment parity for telehealth services delivered to
patients in their homes in the Calendar Year 2024 Medicare Physician
Fee Schedule. However, payment parity will only apply to the services
delivered by urologists as long as the originating site requirement is
waived. Therefore, we urge Congress to permanently waive this
requirement and support CMS' maintenance of payment parity for virtual
care delivered to patients in their homes. Anything less than payment
parity will not be sustainable given the overhead associated with these
visits and the return of more in-person care post-pandemic.
Audio-Only Coverage
Coverage of audio-only visits is a pressing health equity issue. Access
to audio/visual telehealth technology varies widely by socioeconomic
status and geographical location. AUA members' experience has
demonstrated that patients living in poverty or in non-metropolitan
areas are less likely to utilize audio/visual telehealth services.
Additionally, many Medicare beneficiaries, particularly those who are
older, may struggle to establish the simultaneous audio and visual
connections required for telehealth services, either because they lack
access to necessary connection or devices to facilitate simultaneous
audio and visual connections, have difficulty navigating the
appropriate devices, or refuse to appear on camera. For these reasons,
Congress must provide CMS with the authority to cover audio-only
services permanently. The AUA believes this policy supports health
equity and will help reduce health disparities by ensuring Medicare
beneficiaries retain broad access to appropriate services.
Implementation of Guardrails
The AUA recognizes members of Congress' concern with the threat of
fraud and abuse as it relates to telehealth services; however, we are
concerned that implementing guardrails of any kind will only create
barriers to access to necessary healthcare services. The Office of
Inspector General September 2022 report reviewed approximately 742,000
providers offering telehealth services and found that only 0.2 percent
displayed potentially fraudulent billing patterns that warranted
further scrutiny.\7\ Therefore, despite the low incidence of fraudulent
or abusive billing patterns among telehealth providers, the widespread
imposition of guardrails may inadvertently hinder the broader adoption
of telehealth, limiting its potential to enhance healthcare
accessibility. The AUA recommends that Congress refrain from
implementing guardrails to ensure equitable healthcare access for all
Americans.
---------------------------------------------------------------------------
\7\ https://oig.hhs.gov/oei/reports/OEI-02-20-00720.pdf.
Thank you again for the opportunity to provide input and expertise. We
welcome the opportunity to work with you to ensure permanent access to
telehealth. Should you have any questions or require additional
information, please direct your correspondence to Ray Wezik, Director
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of Policy and Advocacy at [email protected].
Sincerely,
Eugene Rhee, MD
Chair, Public Policy Council
Matthew Nielsen, MD
Chair, Science and Quality Council
______
Association for Behavioral Health and Wellness
700 12th Street, NW, Suite 700
Washington, DC 20005
202-449-7660
https://abhw.org/
Dear Chairman Wyden and Ranking Member Crapo,
The Association for Behavioral Health and Wellness (ABHW) appreciates
the Committee's support and leadership in addressing mental health (MH)
and substance use disorder (SUD) issues. ABHW is the national voice for
payers that manage behavioral health insurance benefits. ABHW member
companies provide coverage to approximately 200 million people, both in
the public and private sectors, to treat MH, SUD, and other behaviors
that impact health and wellness. The COVID-19 Public Health Emergency
(PHE) resulted in a rise in mental health disorders. Telehealth has
been a critical modality for those seeking mental health care, and
utilization of tele-mental health services has remained high following
the end of the PHE.\1\
---------------------------------------------------------------------------
\1\ KFF: Telehealth has Played an Outsized Role Meeting Mental
Health Needs During the COVID-19 Pandemic, https://www.kff.org/mental-
health/issue-brief/telehealth-has-played-an-outsized-role-meeting-
mental-health-needs-during-the-covid-19-pandemic/; Healthcare Dive:
Rise of Telehealth During Pandemic Boosted Mental Health Treatment
Rates, https://www.
healthcaredive.com/news/telehealth-mental-health-JAMA-pandemic/639905/.
We appreciate the opportunity to submit a statement for the record
supporting the Committee's efforts to identify solutions and
opportunities to ensure access to telehealth services. Our plans are
invested in ensuring that their members have access to care. We are
pleased to present our priorities for making permanent telehealth
flexibilities after December 2024. ABHW supported the extension of
current telehealth guidance and flexibilities in response to the PHE
through December 2024. These long overdue changes to telehealth
policies have allowed payers and providers to ensure patients can
access necessary MH and SUD services long after the PHE has ended. We
encourage the Committee to consider S. 2016/ H.R. 4189, the Creating
Opportunities Now for Necessary and Effective Care Technologies
(CONNECT) for Health Act of 2023. This legislation makes these
important Medicare flexibilities permanent and expands access to
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telehealth care.
As the Committee considers proposals to make these flexibilities
permanent, ABHW urges the Committee and Congress to address telehealth
policies as soon as possible instead of waiting until December 2024.
Delaying action on these issues until later in the year will result in
confusion as payers often make changes several months before the next
plan year. Making the flexibilities permanent earlier will allow
patients, payers, and providers to make informed decisions and plan for
care.
To strengthen access to telehealth, ABHW recommends the following.
Repeal of the Medicare In-Person Requirements on Tele-Mental Health
ABHW encourages the Committee to repeal the Medicare in-person
requirement on tele-mental health. Many individuals with mental health
disorders may not be able to leave their homes at all or without
significant assistance. Requiring that individuals must have an in-
person visit with a provider within six months before receiving a tele-
mental health service creates an unnecessary and stigmatizing burden to
care. ABHW supports individuals having access to appropriate, quality
care; however, this requirement is an additional difficulty to those
seeking MH services that are not imposed on individuals seeking care
for other medical conditions or SUDs. When making the telehealth
flexibilities permanent, we urge the Committee to include language that
removes the Medicare six-month in-person visit requirement for
patients. ABHW recommends that the Committee work with the U.S. House
of Representatives and consider H.R. 3432, the Telemental Health Care
Access Act of 2023.
Interstate Licensure
During the COVID-19 pandemic, all 50 states used emergency authority to
waive certain aspects of state licensure laws, thus providing
widespread access to care. However, many states have rolled back these
flexibilities. We encourage efforts to foster cross-state licensure
reciprocity to support increased access to services. ABHW proposes that
the Committee consider language for a national task force of federal
and state leaders to examine interstate licensure and outline
recommendations to increase access to behavioral health services.
Medication-Assisted Treatment In-Person Evaluation
Enhancing access to medication-assisted treatment (MAT) is more
critical than ever, with increasing annual deaths from overdoses. The
Centers for Disease Control and Prevention (CDC) estimates that there
were nearly 112,000 deaths in the 12-month period ending in June 2023.
The Kaiser Family Foundation reports that in 2020, 31% of these deaths
were Black, Hispanic, or Asian individuals.
The Drug Enforcement Administration (DEA) in April 2023 released a pair
of rules, one focusing on the telemedicine prescribing of controlled
substances when the practitioner and the patient have not had a prior
in-person medical evaluation; the second rule focused on the induction
of buprenorphine via a telemedicine encounter. Both rules required that
30 days after a telehealth visit, an in-person visit was necessary. The
DEA received 38,000 comments in response to these rules, with a
significant majority expressing concern. Due to the overwhelming
response to the regulations, the DEA extended the COVID-19
flexibilities until November 2023 and again extended the flexibilities
until December 2024.
We encourage you to consider language, removing the in-person
evaluation requirements for MAT. The in-person evaluation before
prescribing controlled substances via telemedicine only results in
reduced access to care. During the COVID-19 PHE, the DEA waived this
requirement, enabling providers to safely prescribe controlled
substances using telemedicine. A Journal of Substance Abuse Treatment
study found that removing the in-person requirement significantly
increased access to care and addressed health inequities in primary
care programs providing buprenorphine treatment.
One way to address in-person requirements is through issuing guidance
on a special registration. This registration would allow clinicians who
want to prescribe a controlled substance via telemedicine without an
in-person visit to register with the DEA. This guidance was required
from the Substance Use Disorder Prevention that Promotes Opioid
Recovery and Treatment for Patients and Communities (SUPPORT) Act of
2018. The DEA has recently signaled a willingness to consider a special
registration for telemedicine, however, it has yet to issue one. The
limited nature of the proposed rules and the uncertainty of issuing a
special registration means that more work needs to be done to ensure
continued telemedicine access to controlled medications.
Coverage of Audio-Only Telehealth Services
Audio-only telehealth services have proven their merit during the
COVID-19 pandemic. ABHW supports the coverage of audio-only telehealth
services when clinically appropriate and supported by evidence. We
recommend its continued use while studies on its efficacy are ongoing.
Additional consideration should also be given to areas with limited
broadband, populations without telehealth-capable devices, or in
necessary situations.
Telehealth Coverage in High Deductible Health Plans
As a part of the Coronavirus Aid Relief and Economic Security (CARES)
Act, telehealth access was expanded to eligible Health Savings Account
(HSA) plans as a pre-deductible benefit. In the face of rising symptoms
of anxiety or depression, employers have worked to provide new and
expanded behavioral health resources to their employees. In 2022, 75%
of large employers offered access to lower- or no-cost mental health
support through their tele-mental health provider, and 33% provided
lower-cost counseling services at the worksite.\2\ By expanding this
HSA safe harbor, employers were able to continue to support individuals
who were leveraging virtual care. We urge you to consider language such
as H.R. 1843/ S. 1001, the Telehealth Expansion Act of 2023, which
would permanently expand this exemption.
---------------------------------------------------------------------------
\2\ Business Group on Health, 2022 Large Employers' Health Care
Strategy and Plan Design Survey: https://www.businessgrouphealth.org/
resources/2022-large-employers-health-care-strategy-and-plan-design-
survey.
We look forward to working with the Committee and other stakeholders to
identify solutions to ensuring access to telehealth after the current
flexibilities end. ABHW urges the Committee to act soon so that
patients, providers, and payers can predict what will occur in 2025. We
thank you for the opportunity to submit ABHW's comments for the record.
If you have any questions, please contact Maeghan Gilmore, Vice
---------------------------------------------------------------------------
President of Government Affairs, at [email protected] or 202-449-2278.
Sincerely,
Pamela Greenberg, MPP
President and CEO
______
ATA Action
601 13th St., NW
Homer Bldg--12th Floor
Washington, DC 20005
The Honorable Benjamin Cardin
Chair
Senate Finance Subcommittee on Health Care
219 Dirksen Senate Office Building
Washington, DC 20510-6200
The Honorable Steven Daines
Ranking Member
Senate Finance Subcommittee on Health Care
219 Dirksen Senate Office Building
Washington, DC 20510-6200
Re: ATA Action Statement for the Record for Senate Finance Subcommittee
Committee Hearing ``Ensuring Medicare Beneficiary Access: A Path to
Telehealth Permanency''
On behalf of ATA Action, the American Telemedicine Associations
affiliated trade association focused on advocacy, thank you for your
continued support of telehealth and holding this critical hearing to
examine a permanent pathway forward for the Medicare telehealth
flexibilities to ensure patients continue to receive care where and
when they need it beyond CY 2024.
Telehealth plays an essential role in our evolving healthcare system
that has proven to expand access to care, reduce costs, assist with
provider shortages, and overall help the health care system become more
efficient and effective.\1\ We appreciate that Congress understands the
value of telehealth and is working in a bipartisan and bicameral way to
ensure that telehealth services are allowed in the Medicare program
after 2024.
---------------------------------------------------------------------------
\1\ PRINT_ATA-TAW-Hill-Day-handout_9.11.23.pdf
(americantelemed.org), https://www.
americantelemed.org/wp-content/uploads/2023/09/PRINT_ATA-TAW-Hill-Day-
handout_9.11.
23.pdf.
Specifically, we urge Congress to make permanent the Medicare
---------------------------------------------------------------------------
telehealth flexibilities implemented during the PHE, including:
Removal of Antiquated Geographic and Originating-Site
Restrictions
Prior to the pandemic, a patient had to be in a designated rural
area and in a healthcare clinic in order to have been able to receive
reimbursable telehealth services under the Medicare program. During the
PHE, the United States Department of Health and Human Services (HHS)
waived these restrictions, thus allowing patients in any geographic
area (not just rural) to receive telehealth services in any location,
including in their homes. We urge Congress to permanently remove the
Section 1834(m) geographic and originating-site restrictions to ensure
that all patients can access care where and when they need it.
Ensure that Federally Qualified Health Centers (FQHCs) and Rural
Health Clinics (RHCs) Continue to Furnish Telehealth Services
FQHCs and RHCs provide critical health care services for
underserved communities and populations across the United States.
During the pandemic, FQHCs and RHCs serve as distant sites and can be
reimbursed for telehealth services. ATA Action urges Congress to ensure
that the roughly 1,400 FQHCs and 4,300 RHCs can continue offering
telehealth services permanently while receiving fair reimbursement.
Permanently Expand the List of Eligible Medicare Providers
During the pandemic, physician therapists, speech-language
therapists, and occupational therapists were able to provide telehealth
services and be reimbursed by Medicare. ATA Action is supportive of
this flexibility and believes all practitioners should have the option
to utilize virtual care when clinically appropriate and be reimbursed
for the services rendered.
Maintain Audio-only Coverage
Congress and the Centers for Medicare and Medicaid Services
(CMS) have expanded access to care since the pandemic, specifically for
those lacking broadband or elderly individuals, by temporarily covering
for audio-only services. ATA Action is modality, service, and provider
neutral, meaning we believe any licensed provider should have the
option to utilize different technologies to deliver care services so
long as it meets the standard of care and is clinically appropriate.
For this reason, we encourage Congress to ensure audio-only coverage is
maintained permanently.
Repeal the Telemental Health In-person Requirement
ATA Action applauds Congress for expanding access and allowing
telemental health services to be a permanent part of the Medicare
program through its passage of the Consolidated Appropriations Act,
2021, Pub. L. 116-260. However, also included was an unnecessary and
unexpected guardrail, an in-person requirement. This provision, which
would go into effect after 2024, requires providers to see their
patients in person no more than six months prior to conducting a
telemental health visit. ATA Action strongly opposes statutory in-
person requirements, as they create arbitrary and clinically
unsupported barriers to accessing affordable, quality health care.
Requirements such as these could negatively impact those in underserved
communities and populations who may not be able to have an in person
exam due to provider shortages, work, lack of childcare, and/or dearth
of other resources.
Over 160 million people in the US live in designated mental
health professional shortage areas.\2\ Many counties have no mental
health professionals at all. We cannot ignore the importance of
providing all Americans, regardless of whether they have seen a
provider in person, with the opportunity to access life-saving health
care. We strongly urge Congress to enact the Telemental Health Care
Access Act (H.R. 3432),\3\ which would remove the statutory telemental
health in-person requirement, allowing patients to receive care where
and when they need it, especially when they are most vulnerable. We
thank Senators Cardin and Thune for their leadership on this
legislation.
---------------------------------------------------------------------------
\2\ Shortage Areas (hrsa.gov), https://data.hrsa.gov/topics/health-
workforce/shortage-areas.
\3\ https://www.congress.gov/bill/118th-congress/house-bill/
3432?q=%7B%22search%22%3A%5
B%22HR+3432%22%5D%7D&s=6&r=1.
Fortunately, Congress agrees with the principles (above) in a
bipartisan, bicameral fashion and have introduced numerous important
pieces of legislation to make various flexibilities permanent. Our top
priorities due to their comprehensive native and widespread support are
the CONNECT for Health Act (H.R. 4189, S. 2016) \4\, \5\ and
the Telehealth Modernization Act (re-introduction pending). We urge
Congress to come together to pass permanency legislation well before
the end of 2024.
---------------------------------------------------------------------------
\4\ https://www.congress.gov/bill/118th-congress/house-bill/
4189?q=%7B%22search%22%3A%5
B%22HR+4189%22%5D%7D&s=5&r=1.
\5\ https://www.congress.gov/bill/118th-congress/senate-bill/
2016?q=%7B%22search%22%3A%
5B%22S+2016%22%5D%7D&s=6&r=1.
While we recognize that this hearing is focused on Medicare
flexibilities, we would also like to raise to policy flexibilities
facing patients in commercial insurance plans which expire on or before
---------------------------------------------------------------------------
the end of 2024.
Flexibility to offer telehealth pre-deductible in high
deductible health plans (HDHPs): In 2020, Congress enacted the
Coronavirus Aid, Relief, and Economic Security (CARES) Act (Pub. L.
116-136) which included a provision that temporarily allowed employers
to offer employees with high-deductible health plans (HDHPs) coupled
with a health savings accounts (HSAs) to receive telehealth coverage
without meeting their deductible while maintaining their eligibility
for HSAs. Congress extended this provision in the omnibus at the end of
2022 extending it alongside the other Medicare flexibilities through CY
2024. We urge Congress to pass the Telehealth Expansion Act (S. 1001,
H.R. 1843),\6\, \7\ which would permanently extend the
exemption for telehealth services from certain high-deductible health
plan rules. It is imperative that the 32 million Americans with HDHP-
HSAs have the ability to continue using these using these lifesaving
services. We thank Senators Daines and Cortez Masto for their
leadership on this legislation.
---------------------------------------------------------------------------
\6\ https://www.congress.gov/bill/118th-congress/senate-bill/1001/
cosponsors?s=8&r=1&q=%7
B%22search%22%3A%5B%22S+1001%22%5D%7D.
\7\ https://www.congress.gov/bill/118th-congress/house-bill/
1843?q=%7B%22search%22%3A%
5B%22HR+1843%22%5D%7D&s=6&r=1.
Flexibility to offer telehealth benefits to workers that don't
otherwise qualify for health care coverage: In 2020, the United States
Department of Health for Human Services (HHS), the Department of Labor
and the Treasury Department jointly issued an FAQ in response to the
COVID-19 pandemic. The FAQ specifically stated that the agencies would
take a non-enforcement position for employers wishing to provide
telehealth or other remote care services to employees ineligible for
any other employer-sponsored group health plan for the duration of the
PHE. This flexibility expired on May 11, 2023 along with the public
health emergency (PHE). Therefore, we urge Congress to action swiftly
to either extend this flexibility for 3 years or pass the Telehealth
Benefit Expansion for Workers Act of 2023 (H.R. 824) \8\ which would
amend the Public Health Service Act, the Employee Retirement Income and
Security Act of 1974, and the Internal Revenue Code of 1986 to treat
telehealth services as excepted benefits. Until Congress acts, millions
of workers will lose access to critical health care services at the end
of this plan year, if they haven't already. (See here for a stakeholder
letter \9\ signed by over 30 organization in support of this
legislation).
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\8\ https://www.congress.gov/bill/118th-congress/house-bill/824/
text?s=3&r=1&q=%7B%22
search%22%3A%5B%22walberg%22%5D%7D.
\9\ https://www.americantelemed.org/wp-content/uploads/2023/09/
Support-for-Expanding-Access-to-Care-for-Employees-FINAL-9.15.pdf.
Again, thank you for hosting this hearing to discuss telehealth
permanency and preparing so far in advance of the CY 2024 expiration
date. We look forward to working with the Senate Finance Committee
members and Congress to ensure the appropriate telehealth policies are
enacted that will provide certainty to beneficiaries and our nation's
health care providers. If you have any questions, please reach out to
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Kyle Zebley ([email protected]).
Kind Regards,
Kyle Zebley
Executive Director
______
Re: ATA Action Recommendations on a DEA Special Registration Process
Thank you for DEA's efforts to hear stakeholder feedback by hosting
public listening sessions to receive comments from healthcare
practitioners, experts, advocates, patients, and other members of the
public to inform DEA's regulations on prescribing controlled substances
via telemedicine. We appreciate the opportunity to expand upon our
comments \10\, \11\ to the March 2023 proposed rules
\12\, \13\ to include recommendations around how to create a
Special Registration process for telemedicine prescribing of controlled
substances.
---------------------------------------------------------------------------
\10\ ATAAction. (2023, March 27). Telemedicine Prescribing of
Controlled Substances When the Practitioner and the Patient Have Not
Had a Prior In-Person Medical Evaluation (Docket No. DEA-407). https://
www.americantelemed.org/wp-content/uploads/2023/03/ATA-Action_DEA-
telehealth-Docket-No.-DEA-407_March-2023.pdf.
\11\ ATAAction. (2023, March 27). Expansion of Induction of
Buprenorphine via Telemedicine Encounter (Docket No. DEA-948). https://
www.americantelemed.org/wp-content/uploads/2023/03/ATA-Action_DEA-bup-
via-telehealth-Docket-No.-DEA-948_March-2023.pdf.
\12\ DEA proposed rule ``Telemedicine Prescribing of Controlled
Substances When the Practitioner and the Patient Have Not Had a Prior
In-Person Medical Evaluation'' on March 1, 2023. https://
www.regulations.gov/document/DEA-2023-0029-0001.
\13\ DEA proposed rule ``Expansion of Induction of Buprenorphine
via Telemedicine Encounter'' on March 1, 2023. https://
www.regulations.gov/document/DEA-2023-0028-0001.
ATA Action, the American Telemedicine Association's affiliated trade
association focused on advocacy, advances policy to ensure all
individuals have permanent access to telehealth services across the
care continuum. ATA Action supports the enactment of state and federal
telehealth coverage and fair payment policies to secure telehealth
access for all Americans, including those in rural and underserved
communities. The ATA represents a broad coalition of health care
providers, including those that exclusively practice telemedicine and
those blending virtual and traditional in-person care. It is a guiding
principle of the ATA that telehealth is health and health care practice
should be regulated on a level playing field regardless of whether in-
person or virtual, and regardless of type of virtual platform. ATA
Action recognizes that telehealth and virtual care have the potential
to truly transform the health care delivery system--by improving
patient outcomes, enhancing safety and effectiveness of care,
addressing health disparities, and reducing costs--if only allowed to
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flourish.
Research supports our statements about the importance of prescribing
controlled substances via telehealth. A national study showed that
utilizing telehealth for medications for opioid use disorder (MOUD)
during the pandemic increased odds of treatment receipt and retention
as well as decreased odds of overdose when compared to in-person
care.\14\ Dr. Shoff, a social science research analyst at the Centers
for Medicare & Medicaid Services (CMS), worked on the study, and stated
``the findings showed that telehealth improved the receipt and
retention of MOUD, suggesting that this method of healthcare delivery
may address common barriers to OUD-
related treatment such as transportation and perceived stigma
associated with OUD.''\15\ Results of a study in Southwestern Ohio
showed that patients who received video-based telehealth services
within 14 days of a substance use diagnosis did not drop out as
frequently when compared to patients who received in-person services
only.\16\ Retention also has been shown to be higher in underserved
communities when telehealth is used. Findings of a study conducted in
Pennsylvania and New York that used a virtual-first telehealth OUD
treatment platform indicated that regardless of race/ethnicity and
geography, retention for buprenorphine use was high:\17\ ``The limited
number of buprenorphine prescribers also makes telemedicine a
particularly attractive option for reaching patients in rural and other
low treatment access areas.''\18\ Instead of embracing modern care that
eases access to potentially life-saving treatment, in-person
requirements do the opposite.
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\14\ Jones, C.M., Shoff, C., Hodges, K., Blanco, C., Losby, J.L.,
Ling, S.M., & Compton, W.M. (2022). Receipt of Telehealth Services,
Receipt and Retention of Medications for Opioid Use Disorder, and
Medically Treated Overdose Among Medicare Beneficiaries Before and
During the COVID-19 Pandemic. JAMA Psychiatry. 79(10):981-992.
\15\ National Institute on Drug Abuse (2022, August 21). Increased
Use of Telehealth for OUD Services During COVID-19 Pandemic Associated
with Reduced Risk of Overdose. https://nida.nih.gov/news-events/news-
releases/2022/08/increased-use-of-telehealth-for-opioid-use-disorder-
services-during-covid-19-pandemic-associated-with-reduced-risk-of-
overdose.
\16\ Gainer, D.M., Wong, C., Embree, J.A., Sardesh, N., Amin, A., &
Lester, N. (2023, January 29). Effects of Telehealth on Dropout and
Retention in Care among Treatment-Seeking Individuals with Substance
Use Disorder: A Retrospective Cohort Study. Substance Use & Misuse. v
58(4), Pages 481-490. https://www.tandfonline.com/doi/full/10.1080/
10826084.2023.2167496.
\17\ Williams, A.R., Aronowitz, S.V., Rowe, C., Gallager, R.,
Behar, E., & Bisaga, A. (2023, March 24). Telehealth for opioid use
disorder: retention as a function of demographics and rurality. The
American Journal of Drug and Alcohol Abuse, v49(2), Pages 260-265.
https://www.tandfonline.com/doi/full/10.1080/
00952990.2023.2180382?src=recsys.
\18\ Lin, L.A., Fernandez, A.C., Bonar, E.E. Telehealth for
Substance-Using Populations in the Age of Coronavirus Disease 2019:
Recommendations to Enhance Adoption. JAMA Psychiatry. 2020 Dec
1;77(12):1209-1210.
With Attention-Deficit/Hyperactivity Disorder (ADHD) on the rise, it is
critical to look at the impacts of telehealth on prescribing practices.
Researchers analyzed over 1 million initial patient visits from more
than 200 large health systems for ADHD and anxiety to compare potential
differences in prescribing practices for telehealth and in-person
visits. The data were from January 1, 2020 through March 31, 2023.
Eighty-four percent (84%) of the initial telehealth visit prescriptions
were for stimulants, which was similar to 87% for patients seen in
person.\19\
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\19\ Bartelt, K., Barkley, E., Butler, S., & Sandberg, N. (2023,
June 27). ADHD Medications Prescribed at Similar Rates During
Telehealth and In-Person Visits. Epic Research. https://
epicresearchblob.blob.core.windows.net/cms-uploads/pdfs/adhd-
medications-prescribed-at-similar-rates-during-telehealth-and-in-
person-visits.pdf.
More than 150 million Americans reside in a federally designated mental
health desert.\20\ Thirty percent (30%) of patients lack local access
to mental health care.\21\ The issue is more pronounced within rural,
low-income, and Black or Brown communities.\22\ To compound the
problem, our country has a mental health care provider shortage with
more than 50% of counties in the country not having a psychiatrist.\23\
The importance of telehealth laws for controlled substances goes beyond
mental health. Cancer patients who are receiving palliative care may
encounter significant challenges with attending outpatient appointments
for reasons such as pain, shortness of breath, lack of energy, and the
use of assistive devices.\24\ These factors make in- person visits even
more difficult for end-of-life cancer patients: ``the rapid adoption of
telemedicine in response to the COVID-19 pandemic has proven to be
highly beneficial for advanced cancer patients and caregivers.'' \25\
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\20\ DEA Telehealth Proposal Brings Risks, Not Patient Protections.
Health Affairs Forefront, March 23, 2023. https://
www.healthaffairs.org/content/forefront/dea-telehealth-proposal-bring-
risks-not-patient-protections.
\21\ Ibid.
\22\ Ibid.
\23\ Ibid.
\24\ Aldana, G.L., Onyinyechi, V.E., & Reddy, A. (2023). Best
Practices for Providing Patient-Centered Tele-Palliative Care to Cancer
Patients. Cancers, 15(6), 1809. https://doi.org/10.3390
/cancers15061809.
\25\ Ibid.
We appreciate DEA's responsibility to write rules that provide
effective controls against diversion and protect public health and
safety, but the requirement that a patient see a clinician in-person is
not an effective control against diversion and, instead, simply limits
access to legitimate health care. ATA Action's comments to DEA's March
2023 proposed rules specifically detail why in-person mandates restrict
access to care and how restricted access to telemedicine will increase
patient harm and diversion risk. We appreciate DEA's efforts to review
and incorporate stakeholder feedback on those comments, including
---------------------------------------------------------------------------
considering the creation of a Special Registration process.
We maintain that in-person requirements are not a clinically
appropriate or effective way to limit diversion and our first
preference would be to permanently waive the in-person requirement as
was done during the COVID-19 public health emergency. However,
practitioners are willing to take extra steps to further demonstrate
their legitimacy when practicing via telemedicine and make themselves
available to DEA scrutiny in order to root out bad actors. Thus, we
respond directly to DEA's questions regarding the creation of a Special
Registration process for that purpose.
We recommend that DEA's approach to regulating the telemedicine
prescribing of controlled substances balance the need to ensure patient
access to care with the need to prevent diversion by considering the
following two principles:
1. Clinical practice should not be limited by non-clinical
decisionmakers.
2. Telehealth is not a type of care, but a modality of care. Rules
should take into account the unique nature of the use of technology as
a modality without arbitrarily restricting its use.
a. Minimum expectation of clinical standards, best
practices, and quality should not vary across modalities for
the same service.
b. However, differences in operations by modality should be
taken into account--just as there are advantages and
disadvantages to receiving a service in a hospital versus a
doctor's office, there are advantages and disadvantages to
receiving a service remotely.
c. Advantages of receiving a service remotely include more
standardized care across a national practice which may result
in higher quality, more convenience and accessibility for both
the patient and the provider, and potentially reduced
infrastructure costs. Increased access to care is critical
given current provider shortages and geographic maldistribution
of providers.
d. The countering disadvantage to increased access to care
via the use of technology is the increased reach that bad
actors may have using technology, which speaks to DEA's
concerns of diversion and overprescribing.
e. We must ensure that DEA has the tools it needs to prevent
diversion without limiting the ability of legitimate
prescribers to practice.
Therefore, to create a Special Registration process for telemedicine
providers seeking to prescribe controlled substances via telemedicine
as a part of their clinical practice, we make the attached
recommendations. These recommendations seek to strike the balance
between ensuring legitimate prescribers can practice, thereby expanding
access to needed health care services using the telehealth modality,
with preventing diversion. Our recommendations are also designed to fit
into DEA's current infrastructure without creating undue burdens for
providers.
Lastly, we urge DEA to consider realistic timelines when implementing
these new processes. We appreciate the ability for stakeholders to
comment on proposed rules and the allowance of adequate time for DEA to
consider such comments. We also emphasize that following a final rule,
DEA should allow adequate time for the healthcare industry to
accommodate new clinical and administrative procedures and update
systems--such as electronic health records, pharmacy management
systems, and license verification systems--to promote compliance.
We are pleased to share these recommendations with the DEA. We also
look forward to commenting once again on any new or modified proposed
rules that DEA puts forth to address telemedicine prescribing post-
pandemic. Please do not hesitate to contact us at any time with
questions or for further discussion.
Sincerely,
Kyle Zebley
Executive Director
ATA Action's Recommendations to DEA for a Special Registration Process
for Telemedicine Prescribing of Controlled Substances Without a Prior
In-Person Visit
September 2023
1. The Special Registration process should work in conjunction with
the existing registration process.
Anyone prescribing, dispensing, or administering a controlled substance
must register with the DEA under the Controlled Substances Act using
form 224 or form 224a for renewals. Form 224 registration is available
to practitioners (MD, DO, DDS, DMD, DVM, DPM), ``mid-level
practitioners'' (NP, PA, OD, RPh, and other entities as recognized by
their state),\26\ pharmacies, hospitals, clinics, and military
practitioners. Currently, DEA requires registration in each state where
the practitioner practices.
---------------------------------------------------------------------------
\26\ Mid-Level Practitioners Authorization by State. (n.d.).
https://www.deadiversion.usdoj.gov/drugreg/practioners/
mlp_by_state.pdf.
Special registration should be an optional supplemental form associated
with the existing registration process and should result in a modifier
on a practitioner's DEA number, such as a ``T'' at the end, to indicate
that the provider has a special telemedicine registration. Providers
should use the modified DEA number when issuing a prescription via
telemedicine. Thus, a provider will have the same registration number
whether they prescribe in person or via telemedicine, but will be able
to indicate both that they have gone through the special registration
process and that the specific prescription was issued via telemedicine
when the DEA number on the prescription includes the modifier. We
encourage DEA to ensure that this type of information can be
---------------------------------------------------------------------------
transmitted in e-prescribing platforms.
2. Telemedicine providers should not be required to maintain local
addresses in every state where they practice.
The value of telemedicine by nature is only fully captured through the
ability to practice across state lines. Improving access to care in
remote areas or areas lacking specific services or providers will only
occur when technology is able to be used to bridge gaps in geography.
The Special Registration process should help realize the potential of
telehealth to address health access issues while maintaining
appropriate oversight of providers.
Providers are already required to obtain state licenses and authority
in the states where they practice. Thus, many telehealth providers hold
multiple state licenses. However, the most significant limiting factor
to a multi-state practice, and the most counter-intuitive, is the
requirement to have a physical location in every state where you
practice. Having a physical address in each state defeats the purpose
of serving patients remotely. Medical boards do not require physicians
to have an in-state brick-and-mortar address in order to obtain a
medical license, and DEA should follow that same approach for
applicants with multistate telemedicine footprints.
In order to obtain a DEA registration, DEA requires applicable state
controlled substances licenses and registrations. During the COVID-19
public health emergency, the requirement to have state authority from
each state where you practice was waived and prescribers could operate
nationwide using one DEA from one state registration. If DEA deems it
necessary to maintain the pre-pandemic requirement that applicable
controlled substances authority or registration be obtained in every
state where the provider practices, the Special Registration process
should allow for such authority to be obtained without the need for a
physical address in each state. For prescribers who are not dispensing,
administering, or otherwise handling or storing a controlled substance
in a state, a physical address in that state should not be necessary.
Practitioners should follow all applicable state laws in states where
they practice, but it is not necessary for a telemedicine provider to
maintain a physical presence in a state where they practice. The
Special Registration process for telemedicine prescribing should
recognize and account for that.
3. Special Registration should include the elements DEA needs to
monitor for illegitimate practitioners and illegal prescribing
practices.
Personal/business information
Address, phone, and email: This is collected in
the standard registration process. Practitioners should be able
to list the site where they practice in person, the site where
they conduct their telehealth practice, or the location of
their practice group office. The purpose of this is not to have
a physical location in each state, but for the practitioner to
be easily contacted by authorities as needed. Thus, the
location must include a phone number and email address at which
the practitioner can be directly reached. It may be a corporate
headquarters if the corporate headquarters has the ability to
directly reach the individual practitioner within a reasonable
timeframe. Practitioners should NOT be required to publicly
list their home address or phone number, even if it is the
location where they practice most often. Limiting the physical
locations will have the added benefit of making it easier for
DEA to monitor an ever-more diverse and mobile prescriber
workforce.
Provider identification number: Prescribers
should register for telemedicine as individuals using their NPI
number.
State authority
State practice licenses: Consistent with DEA
registration, practitioners should provide valid and active
State medical or other clinical licenses to practice, including
supervisory agreement or other authorities, as required by the
state. Practitioners should provide this information for every
state where they have authority to practice.
State controlled substances registration:
Should be provided as applicable, but there should not be a
requirement that providers maintain a physical presence in each
state (see recommendation #2).
States of practice: In addition to and
consistent with state license and controlled substances
authority provided, providers could indicate the states in
which they intend to practice. This would need to be easily
updatable without re-registration as providers obtain authority
to expand into new states.
Proof of malpractice insurance: Practitioners
could provide proof of malpractice insurance.
Background check
Clinicians currently undergo a standard federal
FBI background check as a part of the process to obtain their
clinical licenses. If DEA also requires a background check, it
should utilize a streamlined process to obtain the necessary
information with limited burden on the provider. The DEA should
either access the existing federal background check information
or request a copy from the practitioner.
Attestations--we recommend that the DEA include a list of
required practices that an applicant should attest to adhering to,
potentially including:
Description of practice and clinical protocols:
Similar to the information that practitioners provide when
applying for malpractice insurance, DEA could require a brief
description of a practitioner's practice, including patient
population served and internal and external clinical and
quality assurance protocols in place.
Prescription drug monitoring programs:
Practitioners should attest that they will utilize the
prescription drug monitoring program as required by state law.
Diversion control protocol: Similar to provider
responsibility under HIPAA around maintaining privacy of
protected health information, practitioners could attest to
having practices in place to prevent diversion. Such practices
could include the assignment of a clinical or non-clinical
Diversion Prevention Officer (similar to a HIPAA Privacy
Officer) who is responsible for training staff on identifying
and preventing inappropriate practices and periodically
reporting any violations to DEA using existing suspicious
activity reporting processes. The attestation could include the
question ``does your medical practice have an internal
reporting and investigation process for activity suspicious for
diversion or inappropriate prescribing?''.
Patient identification verification protocol:
Practitioners could attest to utilizing protocols that ensure
patient identity is verified before prescriptions are issued.
Emergency protocols: Practices could attest to
protocols and procedures they have in place to address medical
emergencies during the course of practice.
Training requirement
For all registrants: Starting July 2023, all
new and renewed DEA registrants must complete an 8-hour
training course on addiction medicine, per Substance Abuse and
Mental Health Services Administration (SAMHSA) guidelines.\27\
Special Registration could reiterate the required proof of this
training.
---------------------------------------------------------------------------
\27\ Substance Abuse and Mental Health Services Administration.
Training Requirements (MATE Act) Resources. https://www.samhsa.gov/
medications-substance-use-disorders/training-requirements-mate-act-
resources.
Special Registration training: DEA could add a
one-hour training requirement in order to obtain Special
Registration. This training should not be specific to addiction
services, but should be related to preventing diversion of all
controlled substances and any unique considerations related to
the practice of telemedicine. For example, Washington state now
requires healthcare professionals offering telemedicine
services to complete telemedicine training, which can either be
approved publicly available training or training developed
internally by the practice that meets certain guidelines.\28\
Mechanics of the training could also be pulled from current
HIPAA training requirements.
---------------------------------------------------------------------------
\28\ Washington State Hospital Association. (n.d.). Washington
State Telehealth Training Information. https://www.wsha.org/policy-
advocacy/issues/telemedicine/washington-state-telemedicine-
collaborative/telemedicine-training/.
DEA asks what data is already reported to federal and state
authorities, insurance companies, and other third parties.
Practitioners report prescribing information to state PDMPs as required
by state law or policy. When practitioners contract with insurance
companies, they are often required to report licensing and other
information. It would not be feasible for either practitioners to
report, or for the DEA to receive, data on every prescription at the
patient level as a national system for reporting such information does
not exist and would trigger significant patient health information
privacy and security concerns. It would also be administratively
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burdensome to create a system redundant to the PDMP.
Potentially feasible actions to provide DEA with more visibility into
the prescribing and dispensing landscape and more tools to pursue bad
actors could include:
Requiring that prescribers retain records and share with DEA
upon request.
Requested information could include aggregated,
non-patient-specific, data around prescribing trends over a set
time period.
Requiring that practices proactively report suspicious activity,
including based upon their protocols attested to above.
In one example, a telehealth provider had a
sophisticated system for tracking and verifying patient
identity and was able to identify a ``patient'' illegally
submitting identification for multiple identities. Catching
such an actor would be more difficult in a brick-and-mortar
setting without the use of technological tracking. The
suspicious activity was voluntarily reported to the local DEA,
but there was not a streamlined mechanism to easily share such
information with the DEA.
When reviewing prescribing patterns, it is important for DEA to
consider the population that the telemedicine prescriber serves;
telemedicine prescribers are often specialized into a treatment area
and patients with specific conditions seek them out, so trends may vary
from a provider who sees every type of patient in a geographic area.
Put more directly, the mere fact that a specialized telehealth
practitioner has a high volume of prescriptions of a specific
medication should not, on its own, trigger suspicion.
4. Special Registration should not be limited to any specific
specialty or treatment condition. Schedule II prescribing could involve
additional oversight but should not have additional restrictions.
A wide range of disciplines, including family medicine, internal
medicine, pediatrics, child and adolescent psychiatry, endocrinology,
emergency medicine, and substance use disorder care rely on
appropriately prescribing controlled substances and, therefore, should
not be excluded from the Special Registration process.
ATA Action believes that telehealth is health and that clinical
judgment should be left to the clinician. There are not distinctions
for prescribing of controlled substances for different conditions or
treatments for in-person providers, nor should there be for
telemedicine providers. It would also further restrict access to
certain medications if providers had to obtain another separate
registration to prescribe them.
However, we understand that schedule II medications are classified as
more dangerous than schedule III-V medications and recognize DEA's
interest in particularly limiting diversion of those medications.
Therefore, we recommend the same general Special Registration process
for schedule II-V medications, but with some additional information
required, on the same form, of registrants who indicate interest in
prescribing schedule II medications. We would envision the process
mirroring DEA's current form which distinguishes between narcotics and
non-narcotics. The additional information required could be drawn from
the suggestions in recommendation #3, should not be overly burdensome,
and should maintain clinicians' ability to practice good clinical
judgment.
5. Dispensers (pharmacies and pharmacists) should be able to identify
legitimate prescribers who have a current Special Registration.
Traditional practice of pharmacy often relied on pharmacist-prescriber
relationships in local areas. Especially in the fallout of the opioid
epidemic, pharmacists have been trained to be suspicious of any ``red
flags'' in prescribing patterns and are thus suspicious of prescribers
they are not familiar with or not in their geographic area. This has
resulted in denials to dispense legitimate prescriptions simply because
they were issued via telemedicine, which has negatively impacted
patient care. The Special Registration process should be used to help
dispensers identify legitimate telemedicine prescribers and have
confidence in the legitimacy of prescriptions issued by a prescriber
with a Special Registration, even if from a remote location.
We note that the March 2023 DEA proposed rules contemplated requiring
the prescriber to include a notation on the face of the prescription
that the prescription has been issued via a telemedicine encounter,
which we refer to as a telemedicine ``stamp.'' Clinically, a valid
prescription is a valid prescription and the fact that one was issued
via telemedicine makes it no less so. If the stamp simply indicates
that the prescription was done via telemedicine, we anticipate that
dispensers would simply see it as an additional ``red flag,'' which
would result in further denials to dispense legitimate prescriptions.
If DEA chooses to maintain this prescription ``stamp,'' we recommend
utilizing it to help dispensers identify prescribers who have undergone
the Special Registration process to prescribe controlled substance via
telemedicine, thereby giving the dispenser confidence that the
telemedicine prescription is indeed valid. We recommend that DEA should
make clear that the addition of the ``T'' modifier to the registration
number should explicitly indicate to the pharmacist that the geographic
red flag should not be considered. If possible, we recommend that DEA
create some manner of safe harbor for pharmacists who ignore the
geography red flag based on the prescriber's verified Special
Registration status. Pharmacists still have the corresponding
responsibility to ensure that they fill legitimate prescriptions, but
geography should not be a ``red flag'' in that process when a
prescription is sent by a telehealth provider that has gone through the
Special Registration process.
6. The location of the patient should not require any registration
unless otherwise required because controlled substances are dispensed
or administered at that site.
Patients should be able to receive telemedicine services from their
home or any other location, to include clinics, residential treatment
facilities, halfway houses, jails, juvenile detention centers, prisons,
group homes, rehabilitation centers, schools, qualified hospice
programs, and assisted living facilities. Those locations where the
patient is during the visit should not be required to have any
controlled substances authority. The prescriber prescribing the
controlled substance (and the dispenser dispensing it) should hold the
controlled substances authority, not the location of the patient when
they see the prescriber remotely.
7. The Special Registration process should not place any arbitrary
limits on a clinician's ability to practice within the scope of their
authority.
Prescribers should NOT be limited to treating an arbitrary
number of patients.
Prescribers should NOT be limited to issuing prescriptions for
an arbitrary time period.
DEA should not arbitrarily limit which clinician types have
which authorities or privileges--that is governed by state clinical
practice laws and boards.
Prescriptions should NOT be limited to FDA-approved
indications. It is legal and common for clinicians to use their
clinical judgment to prescribe medications ``off-label.''
______
Cadence
295 Lafayette St., 7th Floor
New York, NY 10012
Dear Health Subcommittee Chair Cardin (D-MD), Health Subcommittee
Ranking Member Daines (R-MT), and Members of the Senate Finance Health
Subcommittee:
Cadence appreciates the opportunity to provide input to the
Committee hearing on ``Ensuring Medicare Beneficiary Access: A Path to
Telehealth Permanency.'' Our expertise is in the better management of
chronic disease through remote physiologic monitoring (RPM), which our
data show improves health outcomes while lowering the cost to the
federal government of providing care for Medicare beneficiaries. We
provide RPM services to over 10,000 patients nationwide. In partnership
with some of the most innovative health systems in the country, Cadence
offers chronic disease management tools and services that give
patients--including those in rural and underserved areas--24/7 access
to our clinical team through cutting-edge technology.
In less than 2 years, we have deployed in 17 states and are
providing life-
changing care to seniors suffering from heart failure, hypertension,
and type 2 diabetes. Cadence data show an approximate 50% decrease in
patients' total cost of care ($4,100 in savings per patient per year),
inclusive of the incremental costs associated with remote monitoring,
and an 18% reduction in the number of emergency department visits for
patients after 6 months in the program. As part of our monitoring, 84%
of Cadence patients take vitals and transmit them to the Cadence
platform at least 16 days per month. With Cadence clinical staff
closely monitoring that data and responding to any anomalies, patients
report feeling safer and more connected to their providers. The
adoption of RPM is also freeing up ordering clinicians to see more
patients through the improved management of those with chronic
conditions, increasing access to care in communities suffering from
shortages of clinical staff.
Testimony presented by Dr. Chad Ellimootil, Dr. Eric Wallace, and
Dr. Ateev Mehrotra on November 14th highlighted RPM's efficacy in
treating and managing chronic illness as well as in reducing
hospitalizations. As Dr. Wallace noted, ``RPM pays for itself.'' We
wish to build on this testimony by requesting that the Committee remove
roadblocks to the adoption and scaling of this innovative technology.
Building on this hearing, we request that the Committee:
(1) Continue to highlight RPM's potential for improving
patient care and reducing Medicare expenditures and work with
the Centers for Medicare and Medicaid Services (CMS) to support
appropriate reimbursement and data collection on the efficacy
of RPM.
(2) Consider addressing geographic disparities in Medicare
payment that prevent providers like Cadence from further
expanding services to rural beneficiaries, leaving potential
savings from improved management of these individuals on the
table. Consistent RPM reimbursement must cover the costs of
providing those services, and currently does not meet that
threshold in many rural areas.
For more detail on Cadence's services, clinical outcomes, and cost
savings for Medicare, please review our comments on the Calendar Year
2024 Physician Fee Schedule Proposed Rule, attached for your reference.
RFI RESPONSE
1. Incorporating RPM in primary care reduces Medicare
expenditures.
Cadence's experience treating and managing thousands of Medicare
beneficiaries alongside primary care providers has made clear that RPM
is key to the future of primary care. Ninety-five percent of the
providers who order our RPM services are primary care providers who
want to improve how they manage their patients' chronic conditions
outside of the office visit. Patients in the Cadence program are highly
engaged and report vitals daily, leading to a 51% decrease in patients'
total cost of care, inclusive of the incremental costs associated with
RPM services.\1\ The program also results in significant improvements
in medication adherence: Our data show a 5x increase in the percentage
of congestive heart failure patients on all four pillars of Guideline
Directed Medical Therapy, the ``cornerstone of pharmacological therapy
for patients with heart failure.''\2\
---------------------------------------------------------------------------
\1\ Calculated as average reduction in total cost of care between
patients enrolled in Cadence versus eligible but never enrolled and
patients enrolled in Cadence versus ordered but never enrolled in
Cadence. Based on ACO data using patients enrolled in Cadence in 2022,
inclusive of over 9,000 eligible patients with congestive heart
failure, hypertension or type 2 diabetes.
\2\ Jay Patel, et al., Guideline-Directed Medical Therapy for the
Treatment of Heart Failure with Reduced Ejection Fraction (2023),
https://pubmed.ncbi.nlm.nih.gov/37254024/.
As part of future deliberations on telehealth, chronic disease, or
rural health, we request that the Committee consider how innovative
models, like Cadence, can continue to help reduce health care spending
through primary care services empowered with digital health management
tools. This effort should be coupled with data collection on the
---------------------------------------------------------------------------
efficacy and cost savings of RPM.
2. Medicare does not appropriately reimburse Rural RPM services,
despite the cost savings RPM demonstrates.
We encourage the Committee to consider the geographic disparity in
reimbursement for RPM, which disincentivizes the adoption of RPM in
rural communities. Cadence is at the forefront of providing remote
monitoring to these communities, as approximately one-third of our
patients live in rural and underserved areas.
While costs for in-person care are primarily related to workforce
costs and often vary geographically, the costs of furnishing digital
health services tend to be more consistent and independent of the
service location. Cadence and many other digital health providers
deliver RPM solutions to patients using the same model of care and
clinical workforce regardless of where patients live, meaning that
identical services (including providing medical devices, educating the
patient on the devices, monitoring physiologic data on an ongoing
basis, and delivering treatment management services) are reimbursed at
different rates under CMS' formula. For example, RPM reimbursement for
data collection (CPT code 99454) in all of Missouri is 61% of what it
is in San Jose, California, even though the costs associated with this
service are largely the same regardless of where it is utilized.
CMS' own data shows that RPM reimbursement is lowest in states
where the prevalence of chronic disease is well above the national
average:
RPM reimbursement is lowest in states where the prevalence of heart failure, hypertension, and diabetes is well
above the national average
RPM reimbursement is 16% less in AL versus WA, despite significantly higher chronic disease prevalence in AL
----------------------------------------------------------------------------------------------------------------
Prevalence of Chronic Disease RPM Reimbursement \2\ Monthly Per
\1\ ------------------------------------ Patient
------------------------------- Reimbursement
-------------------
Ex. Claim with
single units of
HF HTN Diabetes 99453 99454 99457 99458 99454, 99457, and
99458/i.e., one
month of RPM
services)
----------------------------------------------------------------------------------------------------------------
Washington \3\ -2% -12% -5% +11% +11% +7% +6% +8% | $149.87
National Average 14% 57% 27% $19.32 $50.15 $48.80 $39.65 $138.60
Alabama +2% +9% +3% -13% -12% -7% -6% -9% | $126.34
----------------------------------------------------------------------------------------------------------------
\1\ CMS Chronic Conditions Public Use Database. ``Chronic Conditions Prevalence. State/County 2018.'' https://
cms-oeda.maps.arcgis.Pcom/apps/MapSeries/index.html?appid=062934f815eb412182b3d324054ea6f0.
\2\ Reimbursement represents Payment Amounts per the 2023 CMS Physician Fee Schedule in Place of Service 11 (Non-
facility).
\3\ Reimbursement represents the average of the two representative localities: Washington--Seattle (King Cnty) &
Washington--Rest of State.
Unfortunately, current RPM reimbursement is inadequate in many
rural and exurban areas relative to the resources required to create
and maintain an effective program that conforms to CMS' requirements.
High quality RPM is labor-intensive and requires technical expertise.
Costs associated with devices and our technology platform include:
Cellular and Wi-Fi-enabled medical devices. We source and
program each device to upload patient readings automatically to
the Cadence platform. Additional costs associated with devices
include shipping fees; ongoing cellular fees per device; in
certain instances, cellular or Wi-Fi signal boosters to enable
connectivity and avoid data collection disruptions for patients
located in rural areas with poor internet or cellular
connections; and replacement parts or devices.
Continuous patient support. We staff clinical team members
24 hours a day, 7 days a week, and 365 days a year to address
patient and device issues. Labor-intensive and costly around-
the-clock service is necessary to ensure timely care for
patients with chronic and acute conditions and avoid
unnecessary trips to the emergency room. Patients have access
to Cadence 24/7 via text message, phone, and email.
Technology platform maintenance. We sync patient vitals from
our software to the electronic medical record to ensure this
information is captured in the patient's chart. We also staff a
team to improve electronic medical record integrations, which
are far from standardized in the United States today, and
employ full-time software engineers who design and engineer
improvements, address software issues, and ensure the security
of patient information.
Given these concerns, we request that the Committee consider
legislation that would implement a payment adjustment in Medicare by
setting a de facto floor for payment related to RPM. We believe that
the logical approach to determining this floor would be by benchmarking
it to the average payment rate for all geographies, without the rural
payment adjustment included. We recognize this is a significant
request, and are happy to meet with you and present a more
comprehensive look at our cost data justifying this recommendation.
Thank you for your consideration of these recommendations. We
welcome the opportunity to engage with you in greater depth on the
feedback presented above. Please feel free to contact me directly at
[email protected].
Sincerely,
Meryl Holt
Head of Legal
______
September 11, 2023
Administrator Chiquita Brooks-LaSure
Centers for Medicare & Medicaid Services
Department of Health & Human Services
Hubert H. Humphrey Building, Room 445-G
200 Independence Avenue, SW
Washington, DC 20201
RE: Comments on the CY 2024 Physician Fee Schedule Proposed Rule (CMS-
1784-P)
Dear Administrator Brooks-LaSure:
Cadence appreciates the opportunity to submit comments in response
to the Calendar Year 2024 Centers for Medicare & Medicaid Services
(CMS) Physician Fee Schedule Proposed Rule. As a provider of remote
physiologic monitoring (RPM) services to over 10,000 patients across 13
states, we offer general feedback regarding the development of payment
policies for RPM services and responses to specific issues relevant to
our program.
Cadence applauds CMS for its leadership in improving outcomes and
increasing access to life-saving care by introducing coverage for RPM
codes in 2019. The use of these RPM services advances CMS policy
priorities, including improving quality and patient outcomes while
reducing program expenditures. RPM also enables more robust primary
care by supporting the ongoing connection between patient and provider.
As patients and providers continue to experience the benefits of
RPM, we urge CMS to refine its RPM policies to meet the practical
realities and costs of delivering these invaluable services. We
encourage CMS to pursue the growth of demonstrably high-value,
evidence-driven RPM programs. In partnership with over 400 primary care
providers and cardiologists across the United States, our data shows
significantly improved patient outcomes and engagement and reduced
costs to Medicare:
Improved Patient Outcomes
18% reduction in the number of emergency
department visits for patients after 6 months of participation
in the Cadence program, compared to those who had not enrolled.
5x increase in the percentage of congestive
heart failure patients on all four pillars of Guideline
Directed Medical Therapy (GDMT).\1\ For a 70-year-old patient
with heart failure with reduced ejection fraction, achievement
of all four pillars of GDMT provides an additional 5.2 years of
life, on average.
---------------------------------------------------------------------------
\1\ David I. Feldman et al., A Nationwide Telehealth Heart Failure
Program: Can Remote Patient Monitoring and Guideline Directed Treatment
Protocols Help Bridge the Gaps in Heart Failure Management, 29 J. of
Cardiac Failure 4 (April 2023), https://www.onlinejcf.com/article/
S1071-9164(22)00760-6/fulltext.
---------------------------------------------------------------------------
55% increase in the percentage of hypertension
patients with well-
controlled blood pressure.\2\
---------------------------------------------------------------------------
\2\ ``Well controlled'' is defined as less than 140/90 mmHg.
---------------------------------------------------------------------------
43% of type 2 diabetes patients achieved their
blood glucose goal.\3\
---------------------------------------------------------------------------
\3\ ``Blood glucose goal'' is defined as less than 154 mg/dL
(Hemoglobin A1C < 7).
Reduced Costs
51% decrease in patients' total cost of care,
inclusive of the incremental costs associated with RPM
services.\4\
---------------------------------------------------------------------------
\4\ Calculated as average reduction in total cost of care between
patients enrolled in Cadence versus eligible but never enrolled and
patients enrolled in Cadence versus ordered but never enrolled in
Cadence. Based on ACO data using patients enrolled in Cadence in 2022
inclusive of over 9,000 eligible patients with congestive heart
failure, hypertension or type 2 diabetes.
---------------------------------------------------------------------------
63% reduction in the number of ambulance rides
for patients in the program.\5\
---------------------------------------------------------------------------
\5\ Results based on a difference-in-differences analysis using ACO
data using patients enrolled in Cadence in 2022 inclusive of over 9,000
eligible patients with congestive heart failure, hypertension or type 2
diabetes.
Increased Patient Access to Healthcare
More than 4 million vitals transmitted from
home by over 10,000 patients in the last 12 months.
Over 48,000 alerts resolved for all patients.
Over 66,000 remote visits with Cadence clinical
staff.
84% of patients engage with their devices at
least 16 days each month.\6\
---------------------------------------------------------------------------
\6\ Data based on the last 12 months of enrolled patients.
---------------------------------------------------------------------------
80% of patients remain actively engaged after
six months in the program.\7\
---------------------------------------------------------------------------
\7\ ``Actively engaged'' is defined as transmitting at least one
vital per month. Data based on the last 12 months of enrolled patients.
The patient case study below exemplifies the dramatic increase in
patient access, improved outcomes, and decreased costs. Cadence enables
this level of care for tens of thousands of patients across the United
States daily. CMS should encourage the continued growth of RPM to meet
the needs of the millions of beneficiaries who are currently not
---------------------------------------------------------------------------
receiving these services.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
I. Cadence's overarching priorities in the Proposed Rule.
RPM supports highly coordinated primary care and should be
valued accordingly. There is no debate that access to high-quality
primary care produces better health outcomes and equity for
communities.\8\ Over 95% of the thousands of patients enrolled in
Cadence's RPM program had an order placed by their primary care
physician. Yet, RPM reimbursement has not received the attention and
focus within primary care initiatives that we believe is appropriate.
---------------------------------------------------------------------------
\8\ CMS, CMS Announces Multi-State Initiative to Strengthen Primary
Care, June 8, 2023, Press Release, https://www.cms.gov/newsroom/press-
releases/cms-announces-multi-state-initiative-strengthen-primary-care.
Rural Health Clinics (RHCs) and Federally Qualified Health
Centers (FQHCs) should receive RPM reimbursement commensurate with
rates for similar services under the Physician Fee Schedule. We
appreciate that CMS is proposing to institute separate payment for RPM
services in these settings and capture the increased costs associated
with care management services, but the proposed reimbursement under
HCPCS G0511 is insufficient. The payment methodology for the RPM
components does not fully reflect the costs of providing RPM services
in the RHC and FQHC settings and will exacerbate disparities in access
between those who rely on these providers and other Medicare
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beneficiaries.
CMS should reimburse under 99454 for monitoring associated with
each device utilized in the delivery of RPM services. It is often
clinically reasonable and necessary to collect data from two or more
separate medical devices to manage certain conditions and/or
combinations of conditions. Existing reimbursement practically limits
high-cost, high-need patients to monitoring via a single device,
decreasing access to effective care and diminishing the potential for
cost savings to Medicare.
We appreciate CMS' clarification with respect to data collection
requirements for 99453 and 99454, and wish to emphasize that 16 days of
data should not be required to bill treatment management services codes
99457 and 99458. Neither CMS nor the American Medical Association have
endorsed this position previously and there is no medical literature or
other clinical reasoning that supports this change. Such a requirement
would be unnecessarily burdensome and likely limit patient access to
care since all treatment management services would be uncompensated if
a patient failed to submit 16 days of data.
A. RPM supports highly coordinated primary care and should be valued
accordingly.
1. We urge CMS to focus on improving reimbursement for
RPM, just as it has for other primary care
services.
Our experience treating and managing thousands of Medicare
beneficiaries alongside primary care providers has made clear that RPM
is key to the future of primary care. 95% of the physicians who order
our RPM services are primary care providers who want to improve how
they manage their patients' chronic conditions outside of the office
visit. RPM should therefore be an integral part of CMS' ongoing push to
support and enhance primary care services for Medicare beneficiaries.
CMS has already acknowledged the complexity of ongoing primary care
in other contexts outside of RPM services, such as through the creation
of a separate add-on payment, G2211, designed to capture resource costs
associated with evaluation and management visits for primary care and
longitudinal care of complex patients. The Proposed Rule also
recommends a 3% increase in payment rates for family practice.
Additionally, CMS is launching its Making Care Primary Model to
increase access to high-quality primary care services.\9\ The rationale
underpinning these policy decisions should extend to improving
reimbursement for RPM and supporting its integration into other primary
care services.
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\9\ CMS, CMS Announces Multi-State Initiative to Strengthen Primary
Care, June 8, 2023, Press Release, https://www.cms.gov/newsroom/press-
releases/cms-announces-multi-state-initiative-strengthen-primary-care.
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2. RPM reimbursement continues to decline.
Cadence acknowledges and supports CMS' move to recognize RPM as a
primary care service for the purposes of ACO attribution in the
Proposed Rule.\10\ However, we are concerned that CMS has not devoted
adequate attention to reconciling the investment required to deliver
meaningful RPM services with the associated payment rates.
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\10\ 88 FR 52262, 52450 (``We propose to revise the definition of
primary care services used for assignment in the Shared Savings Program
regulations to include the following additions: . . . (2) Remote
Physiologic Monitoring CPT codes 99457 and 99458'').
Reimbursement for the RPM codes tied to recurring services has
declined significantly since 2020, as illustrated in the table below,
despite the increasing costs of devices and labor required to deliver
RPM. While we understand there are a number of factors driving these
payment decreases, some outside of CMS' control, we want to emphasize
the patient access implications of such significant decreases in a
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short period of time for a demonstrably high-value service.
----------------------------------------------------------------------------------------------------------------
2020 2024 (Proposed) % Difference 2020-2024
------------------------------------------------ (Proposed)
-----------------------
Non- Facility Non- Facility Non-
Facility Facility Facility Facility
----------------------------------------------------------------------------------------------------------------
99453 $18.77 N/A $19.65 N/A 4.7% N/A
----------------------------------------------------------------------------------------------------------------
99454 $62.44 N/A $46.83 N/A -25.0% N/A
----------------------------------------------------------------------------------------------------------------
99457 $51.61 $32.84 $48.14 $ 29.15 -6.7% -11.2%
----------------------------------------------------------------------------------------------------------------
99458 $42.23 $32.84 $38.64 $29.15 -8.5% -11.2%
----------------------------------------------------------------------------------------------------------------
As we noted in last year's comment letter,\11\ CMS should take
steps to ensure that the Physician Fee Schedule pays for the clinical
team's work involved in maintaining longitudinal relationships,
providing personalized care, and coordinating across the care team via
RPM. These are high-impact services for both patient outcomes and costs
that should be valued accordingly.
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\11\ Cadence, Comment Letter regarding CY 2023 Physician Fee
Schedule Proposed Rule, August 25, 2022, https://www.regulations.gov/
comment/CMS-2022-0113-15536.
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3. Reimbursement should reflect the resource intensity of
high-quality RPM services.
Cadence's positive clinical and cost-saving results are due to a
nurse practitioner-led clinical team, state-of-the-art technology
platform, and connected medical devices that monitor patient vitals
such as blood pressure, heart rate, blood glucose level, and weight.
Today, Cadence serves patients suffering from hypertension, congestive
heart failure, and type 2 diabetes, which collectively afflict
approximately 65% of Medicare beneficiaries.\12\ Our health system
partners, which include leading academic medical centers and the
largest health systems in the United States, selected Cadence after
unsuccessful efforts to build in-house RPM programs due to complexity
and costs.
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\12\ CMS, Multiple Chronic Conditions, Prevalence State/County
Level: All Beneficiaries by Age, 2018, https://www.cms.gov/research-
statistics-data-and-systems/statistics-trends-and-reports/chronic-
conditions/mcc_main.
Once a practitioner determines the need for RPM, the Cadence care
team educates and instructs the patient on the use of medical devices,
creates a tailored care plan, and begins automatically recording
patient vitals on our technology platform via device transmission. Our
clinical staff reviews these readings before performing regularly
scheduled and as-needed visits to ensure the patient is progressing
toward their care plan goals. Our staff uses guideline-directed care
protocols to respond to alerts, titrate medications, order labs, and
escalate patients to the appropriate care setting. Detailed clinical
protocols and highly trained nurse practitioners are critical to
deliver the highest quality care and to avoid overwhelming primary care
providers who already lack the time to appropriately manage patients
with chronic disease.\13\
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\13\ See Devon McPhee, Primary Care Doctors Would Need More than 24
Hours/Day to Provide Recommended Care, UChicago Medicine, August 3,
2022, https://www.uchicagomedicine.org/forefront/research-and-
discoveries-articles/primary-care-doctors-would-need-more-than-24-
hours-per-day-to-provide-recommended-care.
A tremendous commitment of resources is required to create and
maintain an RPM program that is effective and engaging for patients and
providers, and that conforms to CMS' requirements. High quality RPM is
labor-intensive and requires technical expertise. Our work does not
stop when we hand a device to a patient. Costs associated with devices
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and our technology platform include:
Cellular and Wi-Fi-enabled medical devices. We source and
program each device to upload patient readings automatically to the
Cadence platform. Additional costs associated with devices include
shipping fees; ongoing cellular fees per device; in certain instances,
cellular or Wi-Fi signal boosters to enable connectivity and avoid data
collection disruptions for patients located in rural areas with poor
internet or cellular connections; and replacement parts or devices. We
are aware CMS has resisted payment for cellular and Wi-Fi fees in the
past; we strongly urge CMS to reconsider this position given such fees
are a cost allocated to each patient's device and are more
appropriately characterized as a direct practice expense.\14\
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\14\ See 83 FR 59452, 59575 (``We disagree with the commenters and
we continue to believe that the monthly cellular and licensing service
fee constitutes a form of indirect PE. We believe that licensing and
data costs are administrative costs that are not unique to individual
procedures, in the same fashion that we do not assign separate direct
PE for higher electricity costs to diagnostic imaging procedures as
compared to cognitive evaluation procedures. We continue to believe
that these data costs are appropriately captured via the indirect PE
methodology as opposed to being included as a separate direct PE input.
We also note that other services that require around-the-clock
monitoring, such as the home PT/INR monitoring described in HCPCS code
G0249 . . . do not include additional direct PE inputs for data costs,
and we do not believe it would be appropriate to include them for CPT
code 99454.'').
Continuous patient support. We staff clinical team members 24
hours a day, 7 days a week, and 365 days a year to address patient and
device issues. Labor-intensive and costly around-the-clock service is
necessary to ensure timely care for patients with chronic and acute
conditions and avoid unnecessary trips to the emergency room. Patients
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have access to Cadence 24/7 via text message, phone, and email.
Technology platform maintenance. We sync patient vitals from our
software to the electronic medical record to ensure this information is
captured in the patient's chart. We also staff a team to improve
electronic medical record integrations, which are far from standardized
in the United States today, and employ full-time software engineers who
design and engineer improvements, address software issues, and ensure
the security of patient information.
We recommend that CMS reference Cadence's care model to understand
the investment required to achieve meaningful clinical outcomes and
cost savings when considering RPM reimbursement. We would be happy to
provide CMS with additional data to illustrate these points.
4. CMS should remedy the geographic disparity in
reimbursement.
Relatedly, we also encourage CMS to consider the geographic
disparity in reimbursement for RPM, which disincentivizes the adoption
of RPM in rural communities. While costs for in-person care may often
vary geographically, the costs of furnishing digital health services
tend to be more consistent and independent of the service location.
Cadence and many other digital health providers deliver RPM solutions
to patients using the same model of care and clinical workforce
regardless of where patients live, meaning that identical services
(including providing medical devices, educating the patient on the
devices, monitoring physiological data on an ongoing basis, and
delivering treatment management services) are reimbursed at different
rates under CMS' formula. For example, RPM reimbursement for data
collection (CPT code 99454) in all of Missouri is 61% of what it is in
San Jose, California, even though the costs associated with this
service are largely the same regardless of where it is utilized. Given
the inherently remote nature of RPM and other digital health services,
there is no rationale for CMS to reimburse at different rates based on
geographic location.
Variation in reimbursement and lower reimbursement rates for RPM
provided in lower-cost areas disincentivizes digital health companies
from focusing on rural states and underserved communities that would
benefit from such services. These are the same communities in which
patients often face more barriers to accessing quality care than their
urban counterparts. Three out of five federally designated health
professional shortage areas are in rural regions,\15\ and rural
residents generally must travel farther than urban counterparts to
access healthcare services.\16\ RPM could help address these barriers,
but if providers cannot recoup the costs of providing RPM services in
rural areas they will not offer them. CMS should remedy the disparity
in reimbursement so patients in rural areas are not cut off from
valuable, innovative care.
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\15\ Association of American Medical Colleges, The Complexities of
Physician Supply and Demand: Projections From 2019 to 2034, June 2021,
https://www.aamc.org/media/54681/download?attachment.
\16\ Government Accountability Office, Why Health Care Is Harder to
Access in Rural America, May 16, 2023, https://www.gao.gov/blog/why-
health-care-harder-access-rural-america#::text=
On%20average%2C%20rural%20residents%20are,limited%20access%20to%20health
%20care.
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B. Rural Health Clinics (RHCs) and Federally Qualified Health Centers
(FQHCs) should receive RPM reimbursement
commensurate with rates for similar services under
the Physician Fee Schedule.
Cadence is at the forefront of providing remote monitoring to
patients in rural and underserved areas. Approximately one-third of our
patients reside in non-urban areas, low-income areas, and/or minority
census tracts.\17\ To date, we have been unable to serve patients in
RHC and FQHC settings due to the lack of separate reimbursement for
these services.
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\17\ Federal Housing Finance Agency, Underserved Areas Data,
https://www.fhfa.gov/DataTools/Downloads/Pages/Underserved-Areas-
Data.aspx (``Low-income area'' is defined as: (a) census tracts or
block numbering areas in which the median income does not exceed 80
percent of area median income (AMI), (b) families with income not
greater than 100 percent of AMI who reside in minority census tracts,
and (c) families with income not greater than 100 percent of AMI who
reside in designated disaster areas); Federal Housing Finance Agency,
2022 Low-Income Areas File, https://www.fhfa.gov/DataTools/Downloads/
Documents/Enterprise-PUDB/Low-Income_and_Designated_Disaster_Areas/
LYA_README_2022.pdf (``Minority census tract'' includes any census
tract that has a minority population of at least 30 percent and a
median income of less than 100 percent of the area median income).
We appreciate that CMS is instituting separate payment for RPM
services in RHCs and FQHCs. This is an important first step toward
expanding healthcare access to patients in rural and underserved
communities.\18\ However, the proposed reimbursement of $72 under G0511
is insufficient as the payment methodology for the RPM components does
not reflect the costs of providing RPM services. While some of the
services under G0511 can be offered on a stand-alone basis, it is
frequently the case that at least two RPM services (e.g., daily data
recordings under 99454 plus 20 minutes of treatment services under
99457) are offered simultaneously to meet a patient's needs. We
strongly recommend that CMS consider increasing the reimbursement rate
for G0511 to address the fact that many patients will receive multiple
care management services that under the current proposed approach would
need to be billed under a single bundled HCPCS code.
---------------------------------------------------------------------------
\18\ See Centers for Disease Control and Prevention, About Rural
Health, updated May 9, 2023, https://www.cdc.gov/ruralhealth/
about.html; Centers for Disease Control and Prevention, Diabetes Policy
Brief, https://www.cdc.gov/ruralhealth/diabetes/policybrief.html.
The reimbursement differential between RHC and non-RHC settings is
stark. If a non-RHC provider bills for typical services provided to a
new RPM patient under the 2023 Physician Fee Schedule national payment
rates, in month 1 they will receive $118.27 ($19.32 for 99453, $50.15
for 99454, and $48.80 for 99457) and in month 2 and beyond they will
receive $98.95 ($50.15 for 99454 and $48.80 for 99457), as opposed to
$72 as proposed under G0511. It is unclear what justifies such a
differential given that CMS itself acknowledges that these services
require ``additional resources'' based on their ``unique
components.''\19\ We respectfully request that CMS modify reimbursement
for these sites of service to match the national average payment rates
for comparable RPM services under the Physician Fee Schedule, which
better reflect the complexity of delivering RPM services. Allowing RHCs
and FQHCs to bill codes 99453, 99454, 994547, and 99458 outside of the
all-inclusive rate or prospective payment systems will also prevent
disparities in care based solely on the site of service.
---------------------------------------------------------------------------
\19\ 88 FR 52262, 52401 (``Allowing a separate payment for RPM and
RTM services in RHCs and FQHCs is intended to reflect the additional
resources necessary for the unique components of these services. The
care coordination included in services, such as office visits, do not
always adequately describe the non-face-to-face care management work
involved in primary care. Payment for in-person encounters may not
reflect all the services and resources required to furnish
comprehensive, coordinated care management. As RPM and RTM services are
described, particularly, collection and transmission of data and then
further analysis and interpretation of the data are happening outside
of the face-to-face visit.'').
To the extent CMS moves forward with a single code for RPM
reimbursement in RHCs and FQHCs, we recommend the creation of a new
code for RPM services that is valued separately from the broader G0511
services code and better reflects the costs and needs of an RPM
service. A separate RPM code would mitigate the rationing of care that
is likely to occur given the current make-up of G0511. In its present
form, G0511 can only be billed once per month despite the increasing
number of services providers may offer under the care management
umbrella. The list of services captured under care management already
includes chronic care management (CCM), behavioral health integration
(BHI), principal care management (PCM), and chronic pain management
(CPM), and it continues to grow as items like community health
integration are added.\20\ The diversity of this list means
practitioners will now be forced to choose if their patient will
receive RPM or social determinant support. It is common, however, for
Medicare beneficiaries to have multiple chronic conditions and social
needs, leaving the G0511 code inadequate in covering their care.
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\20\ 88 FR 52262, 52676 (``In section III.B.4. of this proposed
rule, we are proposing a policy to include Remote Patient Monitoring
(RPM), Remote Therapeutic Monitoring (RTM), Community Health
Integration (CHI), and Principal Illness Navigation (PIN) services in
the general care management HCPCS code G0511 when these services are
provided by RHCs and FQHCs.'').
It is notable that CMS is allowing non-RHC/FQHC practitioners to
bill RPM or RTM concurrently with CCM/transitional care management/BHI,
PCM, and CPM.\21\ CMS' stated intention ``is to allow the maximum
flexibility for a given practitioner to select the appropriate mix of
care management services, without creating significant issues of
possible fraud, waste, and abuse associated with overbilling of these
services.''\22\ We request this same flexibility for care management
services billed under HCPCS G0511, so that patients at RHCs and FQHCs
have the same access to care as other Medicare beneficiaries.
---------------------------------------------------------------------------
\21\ 88 FR 52262, 52304 (``Practitioners may bill RPM or RTM, but
not both RPM and RTM, concurrently with the following care management
services: CCM/TCM/BHI, PCM, and CPM.'').
\22\ Id.
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C. CMS should reimburse under 99454 for monitoring associated with
each device utilized in the delivery of RPM
services.
We are disappointed that CMS has reiterated that even when multiple
medical devices are provided to a patient, services associated with all
such devices--in particular, CPT code 99454, which covers the provision
and use of medical devices--may be billed only once per patient, per
30-day period, and when at least 16 days of data have been
collected.\23\ Cadence recommends that CMS discontinue this restriction
and allow reimbursement for patient vitals recorded by each and all
clinically necessary devices.
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\23\ See 86 FR 5020, 5021 (``In response to public commenters, we
are clarifying that only one practitioner can bill CPT codes 99453 and
99454 during a 30-day period and only when at least 16 days of data
have been collected on at least one medical device as defined in
section 201(h) of the FFDCA. CPT language suggests that even when
multiple medical devices are provided to a patient, the services
associated with all the medical devices can be billed only once per
patient per 30-day period and only when at least 16 days of data have
been collected.'').
Limiting reimbursement under 99454 to once per 30-day period
regardless of the number of devices used to record patient data is
unsupported by clinical reasoning and conflicts with typical clinical
practices. There are several scenarios where a provider managing the
care of a patient with a single condition must be aware of two or more
vital signs to make appropriate treatment decisions. For example, a
provider must consider weight and blood pressure before safely managing
the medications of a congestive heart failure patient--especially when
prescribing and dosing GDMT, which involves four drug therapies. GDMT
is proven to reduce mortality and morbidity for patients with heart
failure with reduced ejection fraction, with the potential to mitigate
the staggering annual costs of heart failure in the United States,
which are estimated at over $30 billion.\24\ Yet, over 78% of chronic
heart failure patients are not prescribed GDMT.\25\ CMS' current stance
compounds this problem by barring adequate reimbursement for the
multiple devices required to help providers implement GDMT. Cadence has
firsthand experience with the financial consequences of CMS'
reimbursement policy: even as we have observed a 3x increase in the
percentage of heart failure patients on all four pillars of GDMT while
on our program, one of the two devices needed to manage this condition
is ineligible for reimbursement.
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\24\ Centers for Disease Control and Prevention, Heart Failure,
https://www.cdc.gov/heartdisease/heart_failure.htm.
\25\ Kathir Balakumaran et al., Evaluation of Guideline Directed
Medical Therapy Titration Program in Patients with Heart Failure with
Reduced Ejection Fraction. Int'l J. Cardiol. Heart Vasc. (2018),
https://pubmed.ncbi.nlm.nih.gov/30480083/.
Effectively limiting reimbursement under 99454 to a single device
also negatively affects patients with multiple conditions. For
instance, a provider may have to monitor two or more patient vitals to
make an appropriate treatment decision for a patient with multiple
conditions, like for the many patients with both hypertension and type
2 diabetes (i.e., the provider must monitor blood glucose level and
---------------------------------------------------------------------------
blood pressure, respectively).
Simply put, reimbursement is appropriate under 99454 for all
devices provided to a patient, regardless of the number of conditions
being monitored. This stance is consistent with the guidance set out in
the CPT code book, which contemplates the use of 99453 and 99454 in
connection with one or more ``device(s).''\26\ Accordingly, we
encourage CMS to revisit its position on this issue.
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\26\ American Medical Association, CPT Codebook 2023, Professional
Edition, p. 38.
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D. We appreciate CMS' clarification with respect to data collection
requirements for codes 99453 and 99454, and wish to
emphasize that 16 days of data should not be
required to bill treatment management services
codes 99457 and 99458.
The Proposed Rule states that, for RPM, ``only one practitioner can
bill CPT codes 99453 and 99454 . . . during a 30-day period, and only
when at least 16 days of data have been collected on at least one
medical device.''\27\ CMS also notes that this ``data collection
minimum[] appl[ies] to existing RPM and RTM code families for CY
2024,''\28\ suggesting that at least 16 days of data must be collected
over a 30-day period to seek reimbursement under RPM treatment
management services codes 99457 and 99458.
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\27\ 88 FR 52262, 52304.
\28\ Id. (emphasis added).
To the extent this apparent clarification as to 99457 and 99458 was
intentional, we urge CMS to reconsider it. A 16-day data collection
requirement for these two codes is arbitrary and unreasonable, and
neither CMS nor the American Medical Association has enunciated such a
requirement in previous rulemakings or guidance. To the contrary, CMS
itself has acknowledged ``that a full 16 days of monitoring may not
always be reasonable and necessary.''\29\
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\29\ 85 FR 84472, 84546.
As an initial matter, it would be unreasonable to apply the data
collection minimum to 99457 and 99458 because these time-based services
codes operate on a monthly basis, while data collection code 99454
operates on a rolling 30-day basis. Imposition of the data collection
minimum to the time-based services codes would therefore mean that a
provider who spends 20 minutes with a patient in a month would be
prohibited from seeking reimbursement under 99457 if the patient began
the RPM program in the middle of the month and only had 15 days for
data collection--even if the patient submitted vitals on each of those
---------------------------------------------------------------------------
15 days.
Taking the example of a patient who submits 15 days of vitals in a
given month and receives 20 minutes of treatment management services
one step further, there is no basis--clinical or otherwise--to require
the patient to submit one more day of vitals before reimbursement is
appropriate for treatment management services. We are unaware of any
medical literature that recommends or suggests recording 16 days of
vitals is necessary or even standard to treat and manage a patient's
particular condition. Meanwhile, any and all data recorded in a month
informs care provided to a given patient, and the treatment management
services may reasonably rely on 15 days' worth of data to remotely
manage the patient's status and treatment plan. The treatment
management services may be medically necessary and appropriate services
without regard to whether the 16-day data transmission requirements are
met for codes 99453 and 99454.
We respectfully request that CMS clarify that 16 days of data
collection is not necessary to bill 99457 and 99458. Alternatively, CMS
should make publicly available any additional basis, beyond the CPT
code book instructions, for the 16-day requirement and explain why it
limits coverage of RPM services that are reasonable and necessary for
the treatment of a patient's condition.
II. Additional RPM and care management recommendations.
A. CMS should not require direct supervision of clinical staff
obtaining CCM consent from a beneficiary in an RHC
or FQHC.
Cadence supports CMS' proposal to permanently extend the COVID-19
Public Health Emergency flexibility that allowed clinical staff to
obtain beneficiary consent for CCM services under the general
supervision of the ordering provider in RHCs and FQHCs.\30\ Permitting
beneficiary consent to be obtained under general supervision rather
than direct supervision expands access to valuable CCM services in the
rural and underserved areas that need them the most.
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\30\ 88 FR 52262, 52406.
Further, allowing beneficiary consent to be obtained under general
supervision aligns with CMS' stance regarding all other CCM services,
which are already designated care management services that may be
performed under the general supervision of a physician or other
qualified healthcare provider.\31\ There is no compelling reason for
beneficiary consent to be the only portion of CCM service that must be
performed under direct supervision in RHCs and FQHCs, particularly
because CMS has clarified that the billing requirements imposed on CCM
services ensure that clinical staff are providing appropriate services
even in the absence of direct supervision.\32\ We applaud CMS for
extending the same philosophy to obtaining beneficiary consent for the
CCM services in RHCs and FQHCs.
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\31\ See 42 CFR 410.26.
\32\ 78 FR 74229, 74426 (``We stated our belief that the additional
requirements we impose for auxiliary personnel under the exception for
general supervision for homebound patients in medically underserved
areas should apply in these circumstances where we are allowing a
physician to bill Medicare for chronic care management services
furnished under their general supervision and incident to their
professional services. In both of these unusual cases, these
requirements help to ensure that appropriate services are being
furnished by appropriate personnel in the absence of direct
supervision.'').
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B. CMS should remove the medically unlikely edit (MUE) for 99458 or
increase the number of reimbursable units.
In response to CMS' request for general feedback as it develops
payment policies for RPM,\33\ we propose the removal or increase of the
MUE associated with 99458. CMS has implemented a MUE that bars
providers from billing four or more units of 99458 on a single date of
service. As a result, any time beyond 100 minutes spent delivering care
over the course of a calendar month triggers the MUE and cannot be
billed, improperly restricting a provider's ability to monitor and
manage patients with chronic conditions who require individualized,
frequent care throughout a calendar month.
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\33\ See 88 FR 52262, 52305.
While our data show that the MUE (more than [three] 99458 codes)
are triggered for under 0.5% of patients monthly, it is critically
important to ensure that payment is available for the care delivered to
these patients. The vast majority have congestive heart failure and are
experiencing abnormal vitals readings on a near-daily basis, requiring
close monitoring and care to keep them out of the hospital.
C. An established patient relationship is needed to order RPM
services.
We agree with CMS' continued requirement that there be an
established relationship between the physician and patient prior to
ordering RPM services. This ensures that the ordering physician
understands the needs of the patient in advance of ordering RPM
services and fits well with our vision for RPM as part of highly
coordinated primary care services.
D. CMS should move away from the 20-minute threshold for reimbursement
under treatment management services codes 99457 and
99458.
We welcome the opportunity to discuss with CMS improvements to the
RPM treatment management codes, 99457 and 99458, as the 20-minute
threshold does not adequately reflect how these services are delivered
or utilized. There are situations in the delivery of RPM--e.g., receipt
of a patient vital or phone call requiring immediate intervention--that
result in a significant amount of uncompensated care by providers due
to limitations in how these codes are designed. Approximately 30% of
our clinical team's time is uncompensated today, which is costly given
our multidisciplinary team with a significant number of advanced
practice providers.
Structuring the treatment management codes to resemble primary care
services by offering reimbursement for care furnished during a time
range (e.g., 16 to 23 minutes) as opposed to the strict 20-minute rule
would improve the long-term viability and reach of RPM. As noted above,
RPM is mainly ordered by primary care physicians, and the services are
often utilized similarly to telephonic, non-face-to-face evaluation and
management codes. RPM treatment management services codes should be
modernized to have comparable flexibility.
IV. Conclusion
We appreciate your consideration. Should you have any questions,
require additional information, or wish to meet to review data
supporting our comments, please contact Meryl Holt, Head of Legal, at
[email protected].
Sincerely,
Christopher Altchek
Founder & Chief Executive Officer
______
The Commonwealth Fund
1 East 75th Street
New York, NY 10021
212-606-3800
commonwealthfund.org
Statement of Gretchen Jacobson, Ph.D., Vice President, Medicare
Chair Cardin, Ranking Member Daines, and Members of the Subcommittee on
Health Care,
Thank you for the opportunity to submit a statement for the record
regarding your November 14th hearing, ``Ensuring Medicare Beneficiary
Access: A Path to Telehealth Permanency.''
The Commonwealth Fund is a nonprofit, nonpartisan foundation dedicated
to affordable, quality health care for everyone. We support independent
research on health care issues and make grants to promote better
access, improved quality, and greater efficiency in health care,
particularly for society's most underserved communities.
My comments draw on research by Commonwealth Fund grantees and other
experts on the policy considerations in determining how to handle
expiring Medicare telehealth flexibilities.
A Policy Framework for Evaluating Telehealth Policy
Telehealth holds tremendous promise in improving patient care due to
its convenience and ease of use. However, there have been concerns that
unfettered access can also run the risk of encouraging excessive use of
services and increasing spending with unclear improvements on health.
Telehealth's effects on disparities in access to care are also not
clear-cut. While use of telehealth sharply increased during the
pandemic, many questions remain unanswered about the effects of
telemedicine on access to care, quality of care, spending, and equity,
and how the effects differ across subpopulations.
Telehealth can be an important option for patients who face challenges
in accessing in-person care (e.g., inability to take time off work or
transportation limitations) or who live in underserved areas. But there
have been concerns that lack of access to the reliable broadband and
technology necessary for telehealth visits may exacerbate barriers to
telehealth care for certain communities. A study using 2018 data found
that about 26% of Medicare beneficiaries lacked digital access at home,
with higher proportions among those with low socioeconomic status,
those 85 years or older, and in communities of color.\1\
---------------------------------------------------------------------------
\1\ Roberts, E.T., Mehrotra, A. Assessment of Disparities in
Digital Access Among Medicare Beneficiaries and Implications for
Telemedicine. JAMA Intern Med. 2020;180(10):1386-1389. doi:10.1001/
jamainternmed.2020.2666. https://jamanetwork.com/journals/jamainternal
medicine/fullarticle/2768771.
Dr. Ateev Mehrotra and colleagues offered recommendations soon after
the beginning of the pandemic, within a proposed framework that
prioritizes both high-value medicine and simplicity in regulatory and
payment policy.\2\ They have updated those recommendations to encourage
a nuanced approach toward permanent expansion of telehealth
coverage.\3\ They have highlighted several areas in which more
information is needed to guide policy around telehealth coverage,
including its effects on spending, patient outcomes, and equity. The
researchers suggest that, if the data supports such policies, these
types of nuanced policies could include structuring cost-sharing for
telehealth services differently for low-value versus high-value
services, reimbursing telemedicine visits at a lower rate than in-
person services, increasing the use of alternative payment models, and
requiring physicians to offer video visits if audio-only visits are
also offered.
---------------------------------------------------------------------------
\2\ Ateev Mehrotra, Bill Wang, and Gregory Snyder, Telemedicine:
What Should the Post-
Pandemic Regulatory and Payment Landscape Look Like? (Commonwealth
Fund, Aug. 2020). https://doi.org/10.26099/7ccp-en63.
\3\ Mehrotra, Ateev, and Lori Uscher-Pines. ``Informing the debate
about telemedicine reimbursement--what do we need to know?.'' N Engl J
Med 387.20 (2022): 1821-1823. https://www.nejm.org/doi/full/10.1056/
NEJMp2210790.
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Audio-Only vs. Video Telehealth
As policymakers weigh how to approach coverage and payment for audio-
only telehealth services, they should consider factors like what
modality practices can provide, what providers offer, and what patients
prefer.
A study by Dr. Ishani Ganguli and colleagues found that 43% of Medicare
beneficiaries reported choosing telephone visits when given the option
by their providers, even when video options were reportedly
available.\4\ Older beneficiaries and those with less access to
technology were significantly more likely to choose telephone visits.
This suggests the value of maintaining patients' access to audio-only
services in instances where it's clinically appropriate, such as mental
health care.
---------------------------------------------------------------------------
\4\ Ganguli, Ishani, et al. ``Patient Characteristics Associated
With Being Offered or Choosing Telephone vs Video Virtual Visits Among
Medicare Beneficiaries.'' JAMA Network Open 6.3 (2023): e235242-
e235242. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/
280
2849.
Importantly, the study also found that historically marginalized groups
reported higher rates of telephone visits being offered but similar
rates of uptake among those who were offered. To promote access to
clinically appropriate telehealth services, policymakers should
consider ways to help address practice-, clinician-, and
patient-level barriers to video services. For practices, that could
include financial resources to help build the necessary infrastructure
to offer video visits. For clinicians, that could include regulatory or
payment incentives, such as having providers certify that they offered
both modalities to patients before receiving reimbursement for audio-
only visits. To promote more equitable telehealth access for patients,
policymakers could also build on recent efforts to close the ``digital
divide'' by understanding and closing remaining broadband funding gaps,
prioritizing new infrastructure in underserved areas, and improving
consumer outreach on FCC's program that subsidizes broadband services
for eligible households.\5\
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\5\ Rachfal, C.L. ``The persistent digital divide: Selected
broadband deployment issues and policy considerations.'' CRS Report
R47506. Congressional Research Service (2023). https://
crsreports.congress.gov/product/pdf/R/R47506; https://www.gao.gov/blog/
closing-digital-divide-millions-americans-without-broadband.
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Telehealth for Behavioral Health Services
Tele-mental health care has robust evidence of efficacy across a range
of modalities (e.g., audio-only and video) and conditions (e.g.,
depression and substance use disorder).\6\ Research thus far has
demonstrated that these services are safe, effective, and comparable in
outcomes to in-person mental health services.\7\
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\6\ Jacob C. Warren and K. Bryant Smalley, ``Using Telehealth to
Meet Mental Health Needs During the COVID-19 Crisis,'' To the Point
(blog), Commonwealth Fund, June 18, 2020. https://doi.org/10.26099/
qb81-6c84.
\7\ https://telehealth.org/bibliography/.
A panel of mental health and substance use policy experts and
researchers was convened by Dr. Beth McGinty and colleagues to assess
consensus on how certain
pandemic-era Medicare policy flexibilities might influence care and
costs for beneficiaries with behavioral health conditions.\8\ Most of
the panelists agreed that policies expanding Medicare telehealth
coverage would likely increase access to mental health and substance
use disorder services, and would improve outcomes, but would also
likely increase spending.
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\8\ Beth McGinty et al., Expert Consensus on the Impact of COVID-
Response Medicare Policies on Mental Health, Substance Use Care, and
Costs (Commonwealth Fund, Oct. 2022). https://doi.org/10.26099/5vgp-
e157.
However, experts underscored the need to better understand how
telehealth policies affect access among subgroups of beneficiaries. Are
the policies leading to increased treatment uptake among beneficiaries
who would not get care otherwise or beneficiaries who would get in-
person treatment regardless? This would also determine the effects of
these policies on beneficiaries' out-of-pocket spending (e.g., whether
spending stems from substitutive vs. additive telehealth services).
Interstate Licensure for Specific Physician Telehealth Services
To facilitate care by out-of-state clinicians, the COVID-19 pandemic
prompted the federal government to temporarily relax the requirement
that physicians be licensed in the state where their patient is
physically located at the time of care in order to have the visit
covered by Medicare. State licensing boards play an important role in
verifying the education and training of physicians and ensuring the
safety of patients. Yet, the surge in telehealth use during COVID-19
has prompted concerns from providers who seek to maintain a care
relationship with a patient living in or traveling in another state.\9\
Many health care compliance officers have interpreted ``practice of
medicine'' across state lines to include follow-up calls and electronic
communication. To avoid running afoul of licensing law, patients must
travel to a physician's state of licensure or see a different physician
for their health needs.\10\ This policy affects not just beneficiaries
traveling for leisure but also patients with complex or rare conditions
who must seek out-of-state specialty care that is otherwise unavailable
at home. For behavioral health, policy and research experts have
largely agreed that waiving in-state licensing requirements for
physicians and nonphysician practitioners would increase Medicare
beneficiaries' access to behavioral health services, especially if
telehealth for mental health and substance use disorders is
sustained.\11\
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\9\ Shachar, C., Richman, B.D., Mehrotra, A., Providing Responsible
Health Care for Out-of-State Patients. JAMA. 2023;330(6):499-500.
doi:10.1001/jama.2023.10411. https://jamanetwork.com/journals/jama/
fullarticle/2807774.
\10\ https://hls.harvard.edu/clinic-stories/telehealth-laws-need-
to-be-updated-for-a-post-covid-health-system/.
\11\ Beth McGinty et al.
Faculty at Harvard Law's Petrie-Flom Center and Center for Health Law
and Policy Innovation facilitated a roundtable to identify consensus
among physicians, patients, health systems, academics, and advocates on
proposed telehealth licensure reforms.\12\ The resulting consensus
statement argues for the following exceptions to state-based licensure
requirements, guided by principles of augmented patient access to care,
clarity and uniformity, lower administrative burden and cost, and
expedience:
---------------------------------------------------------------------------
\12\ https://chlpi.org/resources/consensus-statement-for-
telehealth-licensure-reforms/.
Follow-up care for established patient relationships;
Screening for specialty referrals;
Care incident to an existing care plan; and
Care in the context of clinical trials.
The roundtable highlighted that exceptions to state licensure
requirements for patient care have been made in other settings. The
Sports Medicine Licensure Clarity Act created licensure exceptions for
clinicians traveling with a sports team to another state, enabling them
to provide care even if they are not licensed in the state in which the
sporting event occurs. Similarly, the VA MISSION Act created exceptions
for care within the Veterans Administration.
Important questions remain about the efficiency, effectiveness, and
equity of telemedicine policy for Medicare beneficiaries. As more is
learned about the patient outcomes and relative spending on
telemedicine, Medicare coverage and payment policies should be guided
by the evidence.
Thank you again for the opportunity to provide comments for the record.
Please contact Rachel Nuzum, Senior Vice President of Policy at the
Commonwealth Fund at [email protected] and myself at [email protected] if we can be
of further assistance.
______
Medical Group Management Association
1717 Pennsylvania Ave., NW, #600
Washington, DC 20006
T 202-293-3450
F 202-293-2787
mgma.org
November 14, 2023
The Honorable Benjamin Cardin The Honorable Steve Daines
Chairman Ranking Member
Senate Committee on Finance Senate Committee on Finance
Subcommittee on Health Care Subcommittee on Health Care
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Re: MGMA Statement for the Record--Senate Committee on Finance
Subcommittee on Health Care's Hearing, ``Ensuring Medicare Beneficiary
Access: A Path to Telehealth Permanency''
Dear Chairman Cardin and Ranking Member Daines:
On behalf of our member medical group practices, the Medical Group
Management Association (MGMA) would like to thank the Subcommittee for
the opportunity to provide the following feedback in response to your
hearing, ``Ensuring Medicare Beneficiary Access: A Path to Telehealth
Permanency.'' We appreciate your leadership in holding this hearing as
permanent telehealth reform is critical to medical groups' ability to
continue providing high-quality care to beneficiaries nationwide.
With a membership of more than 60,000 medical practice administrators,
executives, and leaders, MGMA represents more than 15,000 group medical
practices ranging from small private medical practices to large
national health systems representing more than 350,000 physicians.
MGMA's diverse membership uniquely situates us to offer the following
policy recommendations.
MGMA has long supported commonsense telehealth policy reforms to expand
access to care. Prior to the COVID-19 Public Health Emergency (PHE),
the utilization of telehealth services was stymied by overly
restrictive regulatory requirements--in 2016, only 0.25% of
beneficiaries in fee-for-service Medicare utilized telehealth
services.\1\ The flexibilities enabled by Congress and the Centers for
Medicare and Medicaid Services (CMS) in response to the COVID-19 PHE
facilitated patients access to critical care through telehealth during
the pandemic.
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\1\ Centers for Medicare & Medicaid Services, ``Information on
Medicare Telehealth,'' Nov. 15, 2018, https://www.cms.gov/About-CMS/
Agency-Information/OMH/Downloads/Information-on-Medicare-Telehealth-
Report.pdf.
We appreciate Congress stepping in and extending many important
telehealth flexibilities that were implemented during the COVID-19 PHE
until Dec. 31, 2024, as part of the Consolidated Appropriations Act of
2023 (CAA, 2023). These policies have allowed practices to continue
offering vital telehealth services to patients wherever they may be
located. We offer the following recommendations on permanent reform
that would build on telehealth's demonstrable success over the past few
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years:
Expand access to telehealth services under the Medicare program
by permanently removing current geographic and originating site
restrictions for all services;
Permanently cover and reimburse audio-only visits at a rate that
adequately covers the cost of delivering that care;
Appropriately reimburse providers for telehealth services to
allow them to provide cost-effective, high-quality care;
Support improving coverage of digital health by removing
administratively burdensome billing requirements, such as the
requirement to collect patient co-pays for virtual check-ins; and,
Ensure continuity of care between a practice and its patients
through telehealth.\2\
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\2\ MGMA, 2023 Digital Health Issue Brief, https://www.mgma.com/
getkaiasset/8bc9a2a9-0c0a-4526-b8ce-fb47520ed320/
MGMA%202023%20Digital%20Health%20Issue%20Brief.pdf.
We propose the Subcommittee examine potential legislation to implement
the polices listed above.
Pass the CONNECT for Health Act of 2023 (CONNECT Act)
The bipartisan CONNECT Act is supported by 60 senators including both
Chairman Cardin and Ranking Member Daines. It would implement many
important policies, such as permanently removing geographic
requirements and expanding originating sites to include the patient's
home and other clinically appropriate sites. Sections of last Congress'
iteration of the bill were used in the CAA, 2023, to extend COVID-19
PHE policies through 2024.
MGMA thanks the Chairman and Ranking Member for their support of the
CONNECT Act and urges the Subcommittee to pass the bill to make
rational permanent reforms to telehealth.
Ensure Practitioners are Safe when Offering Telehealth Services from
Home
In the recently finalized 2024 Medicare Physician Fee Schedule (PFS),
CMS confirmed the continuation of its current policy of allowing
practitioners to list their work address on their Medicare enrollment
form while billing telehealth services from their home until Dec. 31,
2024. During the PHE, CMS allowed practitioners to render telehealth
services from their homes without reporting their home addresses on
their Medicare enrollment forms and allowed billing from their
currently enrolled location. MGMA and other organizations raised the
privacy, security, and administrative concerns with having
practitioners report their home addresses as this information may be
available to the public, and CMS responded by extending its current
policy through 2024.
The House Committee on Energy and Commerce is holding a markup on the
Medicare Telehealth Privacy Act of 2023 tomorrow which would ensure CMS
cannot make a practitioner's home address available to the public if
they offer telehealth services from home. We recommend the Subcommittee
work with its congressional colleagues to pass legislation, such as the
Medicare Telehealth Privacy Act of 2023, to adequately safeguard
practitioners from security and privacy concerns resulting from
reporting their home addresses.
Conclusion
MGMA thanks the Subcommittee for its attention to making permanent
telehealth reforms. We look forward to collaborating with the
Subcommittee and its colleagues to craft sensible policies that will
bolster medical groups' ability to offer high-quality telehealth care.
If you have any questions, please contact James Haynes, Associate
Director of Government Affairs, at [email protected] or 202-293-3450.
Sincerely,
Anders Gilberg
Senior Vice President
Government Affairs
______
Mental Health Liaison Group Telehealth Work Group
1400 K Street, Suite 400
Washington, DC 20005
(818) 288-0684
November 14, 2023
The Honorable Ben Cardin, Chair
Subcommittee on Health Care
U.S. Senate Committee on Finance
United States Senate
Washington, DC 20510
The Honorable Steve Daines, Ranking Member
Subcommittee on Health Care
U.S. Senate Committee on Finance
United States Senate
Washington, DC 20510
Dear Subcommittee Chairman Cardin and Subcommittee Ranking Member
Daines,
Thank you for holding the hearing entitled, ``Ensuring Medicare
Beneficiary Access: A Path to Telehealth Permanency'' at the
Subcommittee on Health Care within the U.S. Senate Committee on Finance
and for your continued leadership to advance telehealth. On behalf of
the Mental Health Liaison Group (MHLG) Telehealth Work Group, we urge
the committee to pass a provision permanently removing the telemental
health in-person requirement as passed within Section 123 of the
Consolidated Appropriations Act of 2021 (P.L. 116-260) prior to the
implementation of the requirement on January 1, 2025.
Although the Centers for Medicare and Medicaid Services (CMS) extended
in-person follow ups to every 12 months after the initial 6-month in-
person visit with the final 2023 Medicare Physician Fee Schedule,\1\
this provision remains unduly burdensome given the growing need for
mental health services throughout the nation and acute behavioral
health workforce shortages. The provision is counter to the intent of
ensuring more Americans receive life changing care; and, in fact, could
further exacerbate our nation's growing mental health crisis. As the
committee is aware, there is no in-person requirement for individuals
seeking medical services or substance use disorder treatment via
telehealth.
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\1\ https://public-inspection.federalregister.gov/2022-23873.pdf.
According to CMS telehealth data \2\ from January 1, 2020 to March 31,
2023, shows approximately 30% of Medicare beneficiaries utilized
telehealth, underscoring the continued popularity of the modality among
enrollees. We also know that Medicare beneficiaries utilize telehealth
for a larger share of their behavioral health services \3\--43% of
beneficiaries for behavioral health services versus 13% of
beneficiaries for office visits (E/M visits). The MHLG Telehealth Work
Group strongly supports in-person care when it is clinically
appropriate; however, the current in-person requirement is applied to
all patients with mental health conditions regardless of whether such a
visit is needed or wanted.
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\2\ https://data.cms.gov/sites/default/files/2023-09/
Medicare%20Telehealth%20Trends%20
Snapshot%2020230821_508.pdf.
\3\ https://oig.hhs.gov/oei/reports/OEI-02-20-00520.pdf.
As the committee continues to negotiate telehealth permanency
provisions, we thank you for your leadership and look forward to
working with you to ensure Americans receive the mental health services
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they need.
Sincerely,
American Academy of Child and Adolescent Psychiatry
American Association for Marriage and Family Therapy
American Association of Nurse Anesthesiology
American Counseling Association
American Foundation for Suicide Prevention
American Psychiatric Association
American Psychological Association
American Telemedicine Association
Association for Ambulatory Behavioral Healthcare
Association for Behavioral Health and Wellness
Centerstone
Children's Hospital Association
Inseparable
Meadows Mental Health Policy Institute
Mental Health America
National Association of Social Workers
National Association of State Mental Health Program Directors
National Council for Mental Well-being
REDC
Wounded Warrior Project
______
National Association for Home Care & Hospice
228 Seventh Street, SE
Washington, DC 20003
Ph: (202) 547-7424
Fax: (202) 547-3540
https://www.nahc.org/
Dear Chair Cardin, Ranking Member Daines, and the members of the Senate
Finance Health Subcommittee,
The National Association for Home Care & Hospice (NAHC) respectfully
submits this statement for the record regarding the hearing titled
``Ensuring Medicare Beneficiary Access: A Path to Telehealth
Permanency.'' Our comments today focus on telehealth policy in the home
care and hospice arena. Since 1982, NAHC has been the largest
organization representing hospice, home health, and home care providers
across the nation. Our members include a wide array of provider types,
including nonprofit and proprietary, urban and rural, hospital-
affiliated, public and private corporate entities, and government-run
agencies.
Home health agencies and hospices have employed many forms of
telehealth in the home setting for more than two decades. Telehealth
has been a valuable tool for providing quality care in an efficient and
effective manner. However, health care programs and payment systems
need to be modernized to take full advantage of telehealth. Following
are key policies applicable to telehealth for in-home care delivery:
Removal of all geographic restrictions on telehealth in Medicare
and allowing the home to serve as a qualifying originating site--The
COVID-19 pandemic has clearly demonstrated the need for telehealth
across settings and in all kinds of communities across the country--
urban, rural, suburban, etc. The pre-pandemic originating site and
geographic limitations are outdated and represent an impediment to the
broader shift to and desire amongst patients, families and providers
for more care in the home. We note that the Centers for Medicare &
Medicaid Services (CMS) already has the statutory authority to
determine the appropriateness of allowing various Medicare services to
be delivered via telehealth; Congress should direct CMS to use this
authority to add clinically appropriate services to the telehealth list
that are evidence-backed and amenable to virtual delivery.
Allowing for the permanent use of telehealth in the
recertification of a beneficiary for the Medicare hospice benefit
(MHB)--A hospice physician or nurse practitioner (NP) must have a face-
to-face (F2F) encounter with every Medicare hospice patient to
determine the continued eligibility of that patient prior to the 180th
day recertification, and prior to each subsequent recertification.
These encounters became difficult and dangerous as the COVID-19 virus
spread and put vulnerable Medicare beneficiaries at high-risk of
serious illness or death. In March 2020, Congress included a provision
in the CARES Act (Section 3706) to specifically allow hospices to
perform the F2F via telehealth for the duration of the PHE. As a result
of the Consolidated Appropriations Act, 2022 (PL No. 117-103), this
allowance was extended through the end of 2024. NAHC's hospice members
report that being able to perform the F2F using telehealth has been a
major success and should be permanently expanded. Hospices are able to
collect all necessary clinical information, follow patient and family
wishes for fewer visits during the pandemic, and allocate staff more
effectively due to this flexibility. A 2020 study \1\ found that
patient and provider satisfaction with virtual F2F visits was high, and
that there were no differences in hospice recertification
recommendations when the F2F was performed either via telehealth or in-
person.
---------------------------------------------------------------------------
\1\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276118/.
Create a payment pathway for services delivered via telehealth
by Medicare home health agencies (HHAs)--Telehealth has been part of
the tools employed by HHAs for two decades. HHAs can use telehealth for
evaluation and assessment of a patient's condition, teaching and
training of self-care and rehabilitative activities, wound care, direct
therapy services, medication management, and more. During the PHE,
Congress also instructed CMS to encourage HHAs to utilize telehealth.
However, unlike for other providers and practitioners, Medicare does
not pay for an HHA's use of telehealth. In fact, the use of telehealth
as a physician-ordered alternative to in-person visits can reduce the
level of reimbursement significantly to HHAs. This occurs because HHAs
receive a payment for a bundle of services for a 30-day period except
when the number of in-person visits falls below a care-specific ``low
utilization'' level. Accordingly, an HHA that combines telehealth with
in-person visits can dramatically cut its reimbursement while not
correspondingly reducing its costs. While a physician, nurse
practitioner, physician assistant, therapist, or other caregivers would
receive payment for each and every telehealth encounter in the home, an
HHA cannot. Congress has previously, on a bipartisan and bicameral
basis, supported Medicare coverage of HH-delivered telehealth in
limited situations, namely federal PHEs (see the 117th Congress' Home
Health Emergency Access to Telehealth (HEAT) Act).\2\ However, we know
enough about the value of virtual visits from Medicare HHAs to do more
than recognize them solely in the reimbursement model during a public
health emergency. Therefore, Congress should allow CMS to waive
prohibitions against reimbursement for telehealth services in the
Medicare Home Health benefit on a permanent basis.
---------------------------------------------------------------------------
\2\ https://www.congress.gov/bill/117th-congress/senate-bill/
1309?q=%7B%22search%22%3A
%5B%22HEAT+home+health+telehealth%22%5D%7D&s=1&r=1.
Coverage of remote patient monitoring in home health--The CY
2021 Home Health (HH) PPS final rule amended 42 CFR 409.46(e) to
include remote patient monitoring (RPM) services consistent with the
plan of care for the individual on the HH cost report as allowable
administrative costs. And beginning January 1, 2023, HHAs may
voluntarily report RPM use on payment claims using a new G-code (code
G0322). Despite these promising steps to advance the tracking and
reporting of RPM use in Medicare HH, as is the case with more
traditional telehealth services, there is no actual reimbursement
mechanism for HHAs that employ RPM in the course of serving patients
and families. The lack of a sustainable payment source for this
valuable tool limits the number of HHAs that are able to utilize it and
dilutes the potential RPM holds to support more proactive, timely, and
responsive care in the home. Therefore, Congress should allow CMS to
waive prohibitions against reimbursement for RPM services in the
---------------------------------------------------------------------------
Medicare Home Health benefit.
We appreciate the opportunity to submit comments on this hearing. We
look forward to ongoing work on these important issues and stand ready
to support efforts on a collaborative basis to strengthen care delivery
through improved telehealth availability. If you have any questions
about this letter or its contents, please contact Calvin McDaniel at
[email protected].
______
National Association of Rural Health Clinics
1009 Duke Street
Alexandria, VA 22314
On behalf of the over 5,400 Rural Health Clinics (RHC) across the
nation, we sincerely appreciate the opportunity to provide a statement
for the record.
The RHC program, first created in 1977, provides outpatient care for
over 60% of rural America \1\ and 11% of the entire country
(approximately 37 million patients). Overall, the Rural Health Clinic
program has been tremendously successful at bolstering access to
healthcare across rural America.
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\1\ https://www.narhc.org/News/29910/Sixty-Percent-of-Rural-
Americans-Served-by-Rural-Health-Clinics.
Telehealth represents a massive opportunity to improve access to care
in rural areas, and we appreciate the Committee's continued efforts to
best understand its impact and value as we consider post-2024 Medicare
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telehealth policy.
Rural Health Clinics and FQHCs were not included \2\ in HHS' emergency
expansion of telehealth policy. For a few weeks at the beginning of the
COVID-19 pandemic, fee-for-service providers were able to offer
telehealth services to their patients, while RHC and FQHC patients were
forced to come in-person to receive a Medicare-
covered healthcare service. The CARES Act \3\ rectified this issue and
allowed RHCs and FQHCs to serve as distant site providers but that
legislation did not allow RHCs and FQHCs to bill for telehealth
normally. Instead, the CARES Act created a ``special payment rule''
that paid RHCs outside their normal All-Inclusive Rate methodology at a
level that is significantly less than what RHCs receive for in-person
services. This stands in stark contrast to traditional physician
offices which receive payment parity between in-person and telehealth
services.
---------------------------------------------------------------------------
\2\ https://www.narhc.org/News/28244/NARHC-Sends-Letter-to-Trump-
Administration-on-Telehealth-Services-During-Covid-19-Pandemic.
\3\ https://www.narhc.org/News/28271/CARES-Act-Signed-Into-Law.
We are concerned with this ``special payment rule'' methodology for a
whole host of reasons. First and foremost, the payment is significantly
less than what most RHCs and FQHCs would receive for providing the same
service in person, disincentivizing safety-net providers from offering
the service via telehealth. Second, the current rules require RHCs and
FQHCs to ``carve-out'' all telehealth costs from their cost report,
which adds significant administrative burden to the cost-reporting
process. Third, the use of a single telehealth code, G2025, billed
whenever an RHC provides one of the 200+ telehealth services
reimbursable by Medicare, has prevented RHCs from tracking annual
wellness visits and other services provided via telehealth properly,
which hinders their ability to properly participate in Accountable Care
---------------------------------------------------------------------------
Organizations and other quality programs.
Complicating matters is the fact that for mental health services
provided via telehealth, RHCs and FQHCs do use their normal coding and
reimbursement mechanisms. This policy is working well, and we believe
that telehealth should work this way for all services, not just mental
health services.
In the 2023 report on Medicare and the Health Care Delivery System,
MedPAC provided RHC-specific telehealth recommendations. Their RHC
recommendations, and NARHC's responses are below.
Ultimately, MedPAC recommends that if Congress decides to permanently
cover
distant-site telehealth services in RHCs and FQHCs that they continue
to reimburse at the rate ``based on PFS rates for comparable telehealth
services,'' which is effectively an endorsement of the current G2025/
special payment rule.
b First, MedPAC stated that ``paying FQHCs and RHCs their standard
rates for all telehealth services would increase costs for the program
and beneficiaries . . . Depending on beneficiaries' supplemental
insurance coverage, these high payment rates (especially for RHCs)
could discourage access because of high out-of-pocket spending.''
MedPAC reported that RHC Medicare spending for telehealth was just 3%
and 2% of total Medicare spending for RHCs in 2020 and 2021,
respectively. Even if granted payment parity, we believe it is highly
unlikely that this would significantly increase overall Medicare
program spending, despite the significant potential benefits for safety
net providers and patients.
b Secondly, MedPAC raised the concern that ``practitioners who
furnish telehealth services do not need to be physically located in an
underserved area, so the higher rates for FQHC- and RHC-provided
telehealth services would not be necessary to ensure access.'' NARHC
agrees with MedPAC that there are currently no limitations as to where
a provider offering telehealth services can be located, but if
telehealth flexibilities are to continue long-term, NARHC believes that
some guardrails may need to be created to ensure that only safety-net
providers serving safety-net patients may receive the enhanced
reimbursement rates. We do not want to create a loophole that allows
patients and clinicians in well-served suburban or urban areas to route
their telehealth billing through the RHC and take advantage of the RHC
reimbursement methodology. Further, the MedPAC recommendation would
disincentivize rural providers from investing in telehealth
technologies and services due to low reimbursement, while incentivizing
urban and suburban providers to offer telehealth services to rural
patients with no physical proximity to them.
Potential guardrails could include requiring
the provider to be in the clinic, some type of service area
requirement, or an occasional in-person visit and we look
forward to continued engagement with the Committee as to
additional options.
b Third, MedPAC stated that ``Paying standard rates for telehealth
visits could also be a disincentive to furnish in-person care since
telehealth visits likely cost less than in-person visits due to reduced
facility costs. Providers should make decisions about what mode of care
is most beneficial to the patient based on clinical considerations, not
on what is most financially advantageous.'' NARHC is not confident that
there is strong evidence, particularly in rural areas, clearly
demonstrating that telehealth costs less to provide than in-
person services. While we disagree with the assumption that RHC
providers would choose a less clinically advantageous mode of care for
their patients based on reimbursement, the fact remains that the
strongest way to ensure that clinical considerations remain the primary
consideration is to pay parity between in-person and telehealth visits.
In its efforts to avoid an incentive to focus on telehealth, MedPAC's
recommendation here is creating a significant financial incentive to
not invest in and recommend telehealth.
b Finally, MedPAC provided the rationale that, ``Because
telehealth services can be delivered to beneficiaries outside FQHCs' or
RHCs' local service areas, paying these providers rates far above PFS
rates could increase costs for the Medicare program and beneficiaries
(without improving access) in areas that are not underserved and could
undermine competition (as clinicians compete to bill under the highest-
paid facility as opposed to competing for patients based on quality and
service).'' MedPAC is raising the concern that if RHCs received payment
parity for telehealth and in-person visits, there would be a financial
incentive for RHC providers to provide telehealth services to non-
rural, medically underserved patients and yet still receive a higher
reimbursement than fee-for-service rates. NARHC agrees that with no
guardrails there is the potential for abuse of the benefit. However,
simply offering lower reimbursement to safety net providers through a
crude special payment rule is not an appropriate guardrail. This
continues to limit safety net providers' ability to invest in these
important technologies. by Congress for mental health services provided
via telehealth.
We are pleased that the CONNECT for Health Act and other pieces of
legislation introduced this Congress would eliminate the special
payment rule in favor of normal payment rules for RHCs and FQHCs and we
urge Congress to rectify this issue, at the latest, as part of any
telehealth extension legislation.
Conclusion
The National Association of Rural Health Clinics thanks the Senate
Finance Subcommittee on Health for organizing this hearing. We hope
that the above statement helps illuminate the unique telehealth policy
position of the 5,400 Rural Health Clinics across the country. Should
the Committee have any questions, the NARHC is happy to serve as a
resource, you may reach us by phone at (202) 543-0348, and email us at
[email protected], or [email protected].
______
National Health Council
1730 M Street, NW, Suite 650
Washington, DC 20036-4561
202-785-3910
https://nationalhealthcouncil.org/
November 28, 2023
The Honorable Ron Wyden The Honorable Michael Crapo
Chair Ranking Member
Committee on Finance Committee on Finance
United States Senate United States Senate
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
The National Health Council thanks the Senate Committee on Finance for
holding a hearing on November 14, 2023, titled, ``Ensuring Medicare
Beneficiary Access: A Path to Telehealth Permanency.'' Access to
telehealth is a significant issue from the patient's perspective, and
we appreciate the opportunity to provide this input in addition to the
providers you heard from directly at the hearing.
Created by and for patient organizations more than 100 years ago, the
NHC brings diverse organizations together to forge consensus and drive
patient-centered health policy. We promote increased access to
affordable, high-value, sustainable, equitable health care. Made up of
more than 150 national health-related organizations and businesses, the
NHC's core membership includes the nation's leading patient
organizations. Other members include health-related associations and
nonprofit organizations including the provider, research, and family
caregiver communities; and businesses representing biopharmaceutical,
device, diagnostic, generic drug, and payer organizations.
The COVID-19 pandemic highlighted and underscored the benefits of
telehealth in providing increased access, ease of use, and comfort with
the health care system for patients with chronic diseases and
disabilities. To help quantify the patient needs in telehealth, the NHC
conducted eight 30-minute listening sessions with staff from the NHC's
patient-organization members.\1\ One of the key themes that arose
during the listening sessions was that telemedicine can help reduce
disparities; however, if it is done incorrectly, it can also exacerbate
disparities. Another theme was that patients should be able to voice
their preference for the type of provider visit they can have, whether
it is in-person, on the phone, or virtually. Concerns over
transportation, mobility, condition type, geography, and privacy could
all change a patient's preference.
---------------------------------------------------------------------------
\1\ NHC-Telemedicine-Briefing-one-pager.pdf
(nationalhealthcouncil.org).
While doctors' offices are operating similar to before the pandemic,
the promise of telehealth is as real as ever for patients living in
rural and underserved communities, those with mobility and
transportation limitations, people with rare diseases working with far
---------------------------------------------------------------------------
away specialists, the immunocompromised, and many others.
Telehealth should be an option for patients and providers, when
preferred and clinically appropriate, and should not supplant in-person
care. Making current Medicare telehealth authority permanent to ensure
continuity of care and access to medically necessary services for
Medicare beneficiaries should be a top priority for Congress before the
current authorities expire next year. In addition, payment policies,
including cost-sharing requirements, and provider networks must still
support access and in-person availability.
During the pandemic, the NHC joined 34 other national patient advocacy
and health organizations on a set of Principles for Telehealth Policy.
We urge you to use these principles as a guide for any telehealth
legislation in order to ensure that the needs of patients are met.
First, we believe telehealth policy can improve access through
equitable coverage, with services covered by all health plans
including, but not limited to, Medicare, Medicaid, the ACA Marketplace,
and other federal and state regulated commercial health plans.
Second, telehealth policy should ease technology barriers. Telehealth
services should be equitably available through easily usable
technologies that are accessible to people with disabilities, with
limited English proficiency, and limited technology. The option of
audio-only communication is especially important for rural and low-
income populations, as many of these patients lack internet access.
Third, telehealth policy should preserve and promote patient choice. A
patient should have the opportunity and flexibility to choose whether
they will access care in-person or via telehealth technologies. In
addition, patients should have limited out-of-pocket costs for
telehealth services and be no more than what they'd pay for an in-
person visit. Insurers should not incentivize nor disincentivize
patients from using one care site over another--the choice should be
based on the right care setting for the patient's individual needs.
Fourth, telehealth policy should remove geographic restrictions, which
place a burden on and can limit both patients and providers when
evaluating treatment options for optimal care. This includes allowing
providers to practice across state lines through telehealth services
increasing access to care and improve care coordination for patients,
particularly in underserved areas.
Recommendation: Make the current Medicare telehealth flexibilities
permanent. And address payment and regulatory barriers that limit
access to telehealth while preserving access to in-person care when
preferred and/or needed.
We know that better access to health care equals better outcomes in the
long run--ultimately reducing cost--and telehealth is proving to be a
valuable tool that should be protected and enhanced in this regard.
Please do not hesitate to contact Eric Gascho, Senior Vice President of
Policy and Government Affairs, if you or your staff would like to
discuss these issues in greater detail. He is reachable via e-mail at
[email protected].
Sincerely,
Randall L. Rutta
Chief Executive Officer
______
Partnership to Advance Virtual Care
The McDermott Building
500 North Capitol Street, NW
Washington, DC 20001
Tel +1 202-204-1460
Fax +1 202-379-1490
https://partnershiptoadvancevirtualcare.org/
November 14, 2023
U.S. Senate Committee on Finance
Subcommittee on Health Care
219 Dirksen Senate Office Building
Washington, DC 20510
Re: November 14, 2023 Health Subcommittee Hearing on ``Ensuring
Medicare Beneficiary Access: A Path to Telehealth Permanency''
Dear Chairman Cardin and Ranking Member Daines:
The Partnership to Advance Virtual Care (PAVC) is pleased to submit
this statement for the record following the Health Care Subcommittee's
November 14, 2023 hearing titled ``Ensuring Medicare Beneficiary
Access: A Path to Telehealth Permanency.''
PAVC's Background and Mission
PAVC is comprised of health systems, health IT vendors, chronic care
specialists, behavioral health providers, and primary care stakeholders
that are leading innovation in telehealth care delivery. We focus the
collective voice of the industry to advocate for regulatory and
legislative policies that improve access to and delivery of telehealth
services.
The COVID-19 public health emergency (PHE) accelerated the revolution
in telehealth care delivery. During the pandemic, enhanced access to
telehealth services served as a lifeline to patients across the
country, allowing patients to access critical health care services
while keeping vulnerable patients out of clinics and hospitals. With
the winding down of the PHE over the course of the past year, and its
official end on May 11th, telehealth continues to play an important
role in our health care delivery system, ensuring continued access to
high-quality health care services and to improve health equity. These
services should continue to be leveraged in order to enhance patient
experiences, improve health outcomes, and reduce health care costs.
Recommendations for Committee Action
PAVC appreciates the committee's focus on Medicare telehealth
permanency. While the Consolidated Appropriations Act, 2023 (CAA, 2023)
extended key telehealth flexibilities through December 31, 2024, it is
imperative that Congress address these extensions prior to the
expiration date. As noted in its final CY 2024 Medicare Physician Fee
Schedule (PFS) rule, the Centers for Medicare and Medicaid Services
(CMS) has stressed its limited ability to provide coverage and payment
beyond the current December 31, 2024, expiration date. Without further
congressional action on these provisions, CMS' ability to contemplate
changes for CY 2025 and beyond will be hindered. Enacting legislation
to further extend Medicare telehealth provisions in advance of the
release of the proposed PFS rule for CY 2025--which is expected in July
2024--would ensure the least amount of disruption for patients and
providers alike.
Consistent with PAVC's mission, we urge the committee to consider and
advance legislation that would:
Permanently extend pandemic-era Medicare telehealth
flexibilities.
Permanently extend the telehealth safe harbor for first-dollar
coverage for those with health savings account (HSA)-eligible high
deductible health plans (HDHPs).
Allow for the classification of telehealth services as excepted
benefits.
Permanent Extension of Medicare Telehealth Flexibilities
The key Medicare telehealth flexibilities extended through December 31,
2024, by the CAA, 2023 include:
Waivers to the geographic and originating site restrictions.
Expansions to the list of eligible practitioners.
Eligibilities for federally qualified health centers (FQHCs) and
rural health clinics (RHCs).
Allowing telehealth to be provided through audio-only
telecommunications.
Allowing telehealth to be used for a required face-to-face
encounter prior to the recertification of a patient's eligibility for
hospice care.
Delaying the in-person visit requirement before a patient
receives tele-mental health services.
PAVC was pleased this 2-year extension was enacted, as it provides some
length of certainty for patients and providers. However, permanency
remains a priority and the extension deadline is quickly approaching.
PAVC has identified the following legislative barriers that would
severely restrict patient access to care through telehealth if not
permanently changed:
Geographic and originating site restrictions. Before the
pandemic, Medicare required that the patient be located in a rural or
certain health professional shortage area and use telehealth in an
approved originating site, such as a hospital or physician office.
Together, these restrictions functionally prevent beneficiaries from
accessing telehealth from a variety of appropriate and more accessible
locations, including their home. Only about 2 percent of beneficiaries
reside in zip codes that meet the traditional geographic and
originating site criteria.
Qualifying providers. Under current policy, the CMS would have
to revert back to policies that restrict the types of providers that
can deliver reimbursable care virtually to Medicare beneficiaries.
Commonly accessed providers like physical therapists, occupational
therapists, and speech language pathologists would no longer be able to
bill for telehealth services.
FQHC and RHC expansion. Without this COVID-19 flexibility, FQHCs
and RHCs will not be allowed to serve as distant site telehealth
providers. This would prevent low-income and geographically isolated
individuals from utilizing telehealth visits to maintain continuity of
care with their existing provider or connect with clinicians best
equipped to meet their needs. This would create barriers to affordable
treatment for the rural and underserved populations who often need it
most.
Audio-only communications. Permanently allowing telehealth to be
provided through audio-only communications is an important component of
ensuring continued access to care. This is particularly relevant in
rural communities, where unavailable or unreliable broadband access
could preclude patients from accessing telehealth through other means.
Face-to-face requirement for hospice care. Permanently allowing
telehealth to be used for a required face-to-face encounter prior to
the recertification of a patient's eligibility for hospice care is
another component of ensuring continued access to care, particularly in
isolated rural and underserved communities.
In-person requirement for mental telehealth services. Enhanced
access to mental telehealth services during the pandemic improved the
lives of many Medicare patients across the country. This included
waiving the in-person requirement for telehealth treatment of certain
mental health conditions. There is no compelling clinical reason to
legislatively mandate an in-person visit for all Medicare patients for
the expanded range of eligible mental health services. Whether a
patient requires an in-person visit prior to commencing their mental
telehealth treatment should be left to the clinical judgment of her
health care provider. The nature of mental and behavioral health care
services does not require in-person assessments with legislated
frequency. In cases where an in-person visit would be warranted,
providers can exercise their clinical judgment.
Taken together, the extension of these provisions will allow for
continued progress toward wider adoption and utilization of telehealth
for Medicare providers and beneficiaries in a post-PHE health care
system. PAVC encourages the committee to advance these policy
extensions.
Permanent Extension of HDHP Safe Harbor (S. 1001)
The safe harbor for first-dollar coverage for telehealth services for
those with HSA-eligible HDHPs was also extended through December 31,
2024 as part of the CAA, 2023. This has allowed employers and health
plans to provide coverage for telehealth services on a pre-deductible
basis for the more than 32 million Americans with HSA-eligible HDHPs.
This commonsense policy has helped ensure families could access vital
telehealth services--including virtual primary care and behavioral
health services--prior to having met their deductible. The ability to
offer pre-deductible telehealth services for employees is a meaningful
expansion of health care access and is popular among consumers.
Notably, according to unpublished estimates from Employee Benefit
Research Institute (EBRI), over 50 percent of individuals with an HSA
live in zip codes where the median income is below $75,000 annually.
This flexibility also enabled expansions of access to care for
individuals who may otherwise have neglected essential care due to high
out-of-pocket costs. Further, a survey by NORC and AHIP found that ``73
percent of commercial telehealth users said Congress should make
permanent the provisions that allowed for coverage of telehealth
services before paying their full deductible.''
We appreciate your efforts earlier this year, Senator Daines, to
reintroduce legislation with Senator Cortez Masto (D-NV) to permanently
extend the HDHP safe harbor. PAVC strongly supports the Telehealth
Expansion Act (S. 1001) and urges the committee to include it in any
forthcoming telehealth extension package, to ensure that this important
source of patient access does not lapse.
Classification of Telehealth Services as Excepted Benefits
Another important telehealth access issue outside of Medicare is the
treatment of telehealth services as excepted benefits under the Public
Health Service Act, the Employee Retirement Income and Security Act of
1974, and the Internal Revenue Code of 1986.
During the PHE, federal agencies issued guidance that they would take a
non-
enforcement position for employers wishing to provide telehealth or
other remote care services to employees ineligible for any other
employer-sponsored group health plan for the duration of the PHE. With
the end of the PHE in May, this flexibility will come to an end at the
conclusion of the current 2023 plan year.
Without action from Congress, the end of this flexibility will be
acutely felt at the end of 2023, as most new plan years begin January
1, 2024. To ensure workers do not lose access to critical services at
the end of the year, we urge the committee to include a temporary,
short-term extension of the PHE non-enforcement policy in any end-of-
year legislative package. Doing so will provide Congress with
additional time to consider and advance a longer-term solution to
ensure continued access to telehealth services for millions of workers.
Summary and Conclusion
The COVID-19 pandemic greatly accelerated the adoption of telehealth
care delivery. Advances in telehealth have made health care more
accessible and equitable nationwide, and PAVC strongly believes that
these advances should remain part of our health care system.
We welcome the opportunity to discuss these issues further. Please do
not hesitate to contact me directly if PAVC can serve as a resource to
the committee, as you work to advance legislation addressing telehealth
policy.
Respectfully,
Rachel Stauffer
Executive Director
______
Letter Submitted by Andrew Smith
Comments on Improving Medicare Finances
Medicare was started in the mid-1960s thanks to President Johnson.
Think of people's longevity back then versus now. And all the new
drugs, medical equipment, surgeries and procedures and better education
of those in the healthcare field today.
Everyone on Medicare pays the monthly premium of $170/month. Then a
person relies on a supplement program for medical and drug prescription
that varies in cost depending on what type of policy a person chooses.
There could be co-pays involved. But maybe not everyone picks up a
supplement for medical.
Medicare is financed by working people who pay 1.45% of their W-2
income as well as their employer. But what happens to the spouse who
does not work? That person is entitled to Medicare but has not paid one
cent into the Medicare Trust Fund. Or the new immigrant becoming a U.S.
citizen in their 40s. They are entitled to Medicare but may have paid
only since they started working in the U.S. Or maybe bring in a senior
person like a grandparent.
There is no Medicare tax on investment income under a certain income
level. The person who invests for a living is entitled to Medicare but
may not be paying into the Medicare Trust fund.
When someone loses their job, they are not paying into the Medicare
Trust Fund until they get back working. If the economy is bad, that
person could be jobless for over a year or more not paying into the
Medicare Trust Fund.
Many government workers have retirement policies that don't rely on
Medicare for retirement healthcare. A whole segment of the population
could be paying into the Medicare Trust Fund.
Question should be on the raising of the 1.45% Medicare Trust Fund tax
to maybe 2% on W-2 income for the employee and employer. And maybe the
family that the spouse not working paying some money into the Medicare
Trust Fund.
The Affordable Care Act of 2010 included a provision for a 3.8% ``net
investment income tax,'' also known as the Medicare surtax, to fund
Medicare expansion. But only applies to a certain income level. A
Medicare surtax of 3.8% is charged on the lesser of (1) net investment
income or (2) the excess of modified adjusted gross income over a set
threshold amount. The threshold is $250,000 for joint filers, $125,000
for married filing separately, and $200,000 for all other filers.
Relying on drug prescription negotiations to decrease the cost is just
one method to help on cost control. But if the amount is only 50 drugs,
how much does that save Medicare?
So where else can Medicare get the income to feed the trust fund?
Should a national tax be used and on what type of product or service
and how much?
Is anyone looking at this side of the Medicare equation?
Andrew Smith
Santa Rosa, CA
______
Society of Thoracic Surgeons
STS Headquarters
633 N Saint Clair St., Suite 2100
Chicago, IL 60611-3658
(312) 202-5800
https://www.sts.org/
Washington Office
20 F St., NW, Suite 310 C
Washington, DC 20001-6702
https://www.sts.org/topics/advocacy
November 14, 2023
The Honorable Benjamin L. Cardin The Honorable Steve Daines
Chairman Ranking Member
U.S. Senate Committee on Finance U.S. Senate Committee on Finance
Subcommittee on Health Care Subcommittee on Health Care
Washington, DC 20510 Washington, DC 20510
Dear Chair Cardin and Ranking Member Daines,
On behalf of The Society of Thoracic Surgeons (STS), I write to provide
feedback on the important issues raised during the Subcommittee's
hearing ``Ensuring Medicare Beneficiary Access: A Path to Telehealth
Permanency.'' Founded in 1964, STS is a not-for-profit organization
representing more than 7,700 surgeons, researchers, and allied
healthcare professionals worldwide who are dedicated to ensuring the
best possible outcomes for surgeries of the heart, lungs, and
esophagus, as well as other surgical procedures within the chest.
We thank you for holding this hearing to address the critical issues
facing physicians and patients, including increasing access to care
through telehealth expansion. We appreciate the opportunity to share
our perspective on the interventions needed to ensure the proven
benefits of telehealth services continue to be available for patients
when appropriate.
Data collected during COVID-19 demonstrates the positive impact
telehealth has had on both patient clinical outcomes and patient
experiences. A 2020 study by the National Institutes of Health (NIH)
found telemedicine to be beneficial in both acute care and chronic
disease management. Results from the study suggest that it is
equivalent to in-person care for health outcomes in certain conditions
and may also decrease short-term hospital and emergency department
utilization. Additionally, research shows that the use of telehealth
provides access to care despite geographic barriers, reduces burden on
medical infrastructure, and lessens exposure to infectious diseases for
all participants. Advances in technology and the advent of more
sophisticated equipment has increased the extent of patient monitoring
via telemedicine and has resulted in increased physician and patient
satisfaction. Enacting permanent telehealth policy will help provide
more predictability and help foster greater investment into this
critical tool.
Currently, many essential Medicare telehealth flexibilities are set to
expire on December 31, 2024. The STS encourages Congress to enact a
permanent extension of these flexibilities to ensure that patients can
maintain a stable relationship with their health care provider via
telehealth services, which is especially important for rural and
underserved communities. The STS appreciates the Committee's long-time
leadership on this issue, including during the COVID-19 pandemic, and
even earlier in the 2018 CHRONIC Care Act. Going forward there are two
legislative proposals that STS would like to bring your attention to:
S. 2016, the Creating Opportunities Now for Necessary and Effective
Care Technologies (CONNECT) for Health Act, and S. 1636, the Protecting
Rural Telehealth Access Act.
STS supports the CONNECT for Health Act to ensure that Medicare
patients can maintain a stable relationship with their health care
provider via telehealth services, which is especially important for
rural and underserved communities. Given the uncertainty of whether the
Centers for Medicare and Medicaid Services (CMS) will extend telehealth
provisions past 2024 independently, this legislation is necessary to
facilitate that connection. Additionally certain barriers are rooted in
statutory restrictions that require action by Congress, such as
geographic and originating site restrictions. Nearly two-thirds of the
Senate has cosponsored this legislation, showing the broad consensus
around these important issues.
We also support the Protecting Rural Access to Telehealth Act. This
legislation would make permanent Medicare coverage of telehealth
services allowed during the COVID-19 pandemic and specifically
recognizes the important and unique role of audio-only services. In
many situations, audio-only telehealth provides the only means for
essential care, especially for those who do not have adequate internet
coverage or have difficulty operating a computer.
Lastly, we want to highlight our concerns over provider safety for
those offering telehealth services. The provision of remote health care
services offers great benefit to patients receiving the services and to
the providers offering them. Allowing appropriately licensed and
credentialed providers to practice telehealth from their home improves
patient access to healthcare services, reduces healthcare costs, while
maintaining and meeting patient demand for care. However, it is not
practical, workable, or safe to require a provider to publicly report
their home address as their practice location. Medicare providers
should not be compelled to share their personal information, especially
when it relates to their home addresses. In an environment in which
threats against healthcare professionals have markedly increased, the
safety and privacy of physicians must be paramount. During the
pandemic, CMS allowed providers to report their practice address
instead of their home address when billing telehealth services. In the
2024 Medicare Physician Fee Schedule final rule, CMS extended these
protections until December 31, 2024. However, to continue the goal of
ensuring safety for providers, we believe this provision needs to be
extended indefinitely. We urge the Committee to consider the Telehealth
Privacy Act of 2023 which would directly address these concerns.
Thank you for the opportunity to provide these comments. Please contact
Molly Peltzman, Associate Director of Health Policy, at
[email protected] or Derek Brandt, Vice President of Government
Affairs, at [email protected], should you need additional information or
clarification.
Sincerely,
Thomas E. MacGillivray, M.D.
President
______
UNC Health
101 Manning Drive
Chapel Hill, NC 27514
UNC Health is North Carolina's largest not-for-profit, academic,
integrated system owned by the state of North Carolina. Our primary
focus, approach and commitment is to improve North Carolinians' health
in the 21st century. Headquartered in Chapel Hill and affiliated with
the University of North Carolina School of Medicine, UNC Health is
composed of 14 hospitals, 20 hospital campuses, one virtual hospital
and more than 800 clinic locations across North Carolina. Founded with
N.C. Memorial Hospital in 1952 the healthcare system was established
November 1, 1998, by N.C.G.S. 116-37.
Our mission is to improve the health and well-being of North
Carolinians and others whom we serve. We accomplish this by providing
leadership and excellence in the interrelated areas of patient care,
education and research.
Executive Summary
Telehealth is an important modality of health care delivery that
increases patient access to high quality care in our rural, urban, and
underserved communities.
Pre-pandemic regulations, policies, and financial disincentives
created barriers that prevented the use and expansion of telehealth in
both primary and specialty care settings.
The COVID-19 pandemic flexibilities listed below that have been
extended through 2024 have allowed for significant expansion of
telehealth services in the outpatient setting, providing easy access
and use of audio- only and audio-video visits for patient in all
geographic locations.
Use of audio-only visits.
Payment parity for telehealth visits.
Removal of regulations that limited when a
telehealth visit can take place and where the patient has to be
located.
It is imperative that we make these flexibilities permanent to
ensure the continued growth of telehealth and improve access to health
care for all patients.
Telehealth trends at UNC Health
Over the last few years, there has been a significant surge in the use
of telehealth to deliver high quality health care, mainly driven by the
increased flexibilities brought on by the COVID-19 pandemic. Some of
these flexibilities included the removal of geographic barriers in
providing telehealth, coverage of audio-only telehealth, and
reimbursing audio/video visits at the same rates of reimbursement as
in-person visits. And while it's been noted that rates of telehealth
utilization have decreased since the height of the pandemic, in 2023
UNC Health has continued to serve communities across our state with an
average volume of 18,424 primary care and specialty care telehealth
visits per month (8.48% of all outpatient visits), with about 24% of
these telehealth visits being audio-only visits. The pandemic era
flexibilities demonstrated that by removing specific barriers, we can
deliver more timely and higher quality primary and specialty care to
our patients both in rural and urban settings. Allowing easy access to
both modalities of telehealth is crucial to providing equitable care
across our state. UNC Health supports making certain pandemic era
flexibilities, such audio-only visits, payment parity, and the removal
of specific regulations, permanent. The ability for us to expand
telehealth and deliver better care to more patients across North
Carolina is largely due to the coverage of all telehealth visits and
the expanded payor parity with video visits. We are concerned that if
pre-pandemic telehealth restrictions go back into place after December
31, 2024, telehealth visits will drop, and we will see regression in
access to care for patients across our state at a time when we are
expanding our Medicaid program.
Access to Care
Not all patients have equal access to care, but telehealth can
alleviate some of this. Living in a rural area may mean you're required
to travel long distances to receive care. Working multiple jobs or
being unable to leave work for an appointment means your care is
delayed. Our patients consistently report that telehealth allows them
to seek out health care they would have otherwise avoided which leads
to poorer overall outcomes and higher societal costs. Access to
telehealth reduces barriers to care like transportation, missing work,
and childcare, while still providing access to primary and specialty
care.
Loss of Payment Parity
Allowing providers to charge for telehealth as they charge for in-
person visits is essential to the success of telehealth. Billing for
in-person visits no longer requires physical elements to be completed,
but rather places the focus on patient complexity, medical decision-
making, and time. Because a physical exam is no longer a requirement,
and because complexity can be the same for telehealth and in-person,
the elements required to bill for in-person care can and should align
with the elements required to bill for telehealth.
In addition, most telehealth is provided by clinicians who see patients
both in-
person and virtually, meaning overhead expenses, employee salaries, and
other expenses are not reduced just because a provider sees a portion
of their patients virtually. In fact, the brick-and-mortar office is
still necessary based on the nature of the practice. Telehealth is
often used in a hybrid model where a patient will come in when
bloodwork or a physical exam is needed but will see their provider
virtually when possible. Therefore, telehealth providers do not have
lower expenses than in-person-only providers and payment parity is
necessary for all telehealth providers.
Loss of Audio-Only Coverage
Audio-only telehealth continues to be used by many patients as their
point of access to care and should be covered by insurance. At UNC
Health, we conduct an average of 4,455 audio-only visits per month. As
stated above, many patients, including rural patients without easy
access to in-person care, do not have access to Wi-Fi or a device with
a camera which would give them access to telehealth via video visits,
meaning they use audio-only telehealth. Nationwide broadband
initiatives and other programs working to expand internet access may
reduce the need for audio-only visits in the future while moving to
video visits, but we have not yet reached a state where this is the
case.
While audio-only visits often work for both patient and provider,
without insurance coverage for audio-only visits, clinicians will not
be able to provide audio-only visits and will require patients to come
in-person, reducing the access to care provided by telehealth and
creating inequities.
Regulation Barriers
The telehealth guardrails listed below are not evidence-based and are
not clinically necessary. These guardrails also create barriers to
accessing telehealth and should be permanently removed.
In-Person Guardrail: UNC Health believes that there is no clinical
benefit to requiring a patient to be seen in-person before utilizing
telehealth or periodically while also utilizing telehealth. The
complexity of and reason for visits are often the same for in-person
and telehealth. The results of the visits are also the same:
evaluation, diagnosis, treatment, prescriptions, a summary of the visit
and patient education. Since in-person and telehealth visits are
equivalent, there is nothing to be gained by requiring a patient to
come in person before they're able to receive care via telehealth.
While some visits require patients to come in-person, there is often no
medically necessary reason to require a patient to be seen in-person
when the same visit can be had via telehealth.
Geographic Guardrail: Telehealth use should not be limited to rural
populations. Upon first thought, it makes sense that rural areas would
need telehealth more due to the barriers to in-person care such as
logistics and cost of transportation. Upon second thought, many
patients in urban areas also have barriers to transportation like rural
patients. Many urban areas do not have public transportation, are not
pedestrian-friendly, or may not be safe to walk. This leaves patients
in urban areas in the same position as patients in rural areas: they
need telehealth to access care. UNC Health serves both rural and urban
populations through telehealth, shown on the map below.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Originating Site Guardrail: It should not be a requirement for
patients to access telehealth onsite at a healthcare facility. While
patients who don't have access to the technology needed for telehealth
may benefit from telehealth delivery at their local clinic, requiring a
patient to receive telehealth at a healthcare site negates one of the
main benefits of telehealth--removing accessibility barriers. Patient's
homes have served as functional sites to receive telehealth for the
last few years without detriment and only positive outcomes.
Furthermore, there is a societal benefit in not exposing others to
contagious diseases if they can be treated at home. There is no need to
require a patient to travel to a specific site to receive telehealth
services.
Summary
While this document is not comprehensive, it does contain a list of
first steps the Senate should take to ensure viability of and access to
telehealth. In short, the telehealth flexibilities enacted due to the
COVID-19 pandemic are still imperative for telehealth today and should
not expire on December 31, 2024. Permanently ensuring payment parity,
permanently removing guardrails not backed by evidence, and allowing
audio-only coverage past 2024 are essential elements to the continued
success of telehealth and maintaining access to high quality health
care for all patients.
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