The COVID-19 crisis is an acid test for the value of telehealth and remote medicine in patient-centered and community care. Our 2018 Telehealth report described the opportunities and regulatory environment telehealth contended in. Now, new exceptions and regulations by CMS, the Office for Civil Rights, and the FDA are easing access, deployment, and promoting the use of telehealth and remote care in the hopes of reducing strain on an over-taxed healthcare system. While these changes are being forced due to an episodic event, COVID-19, there is a strong likelihood that the changes will become systemic, forever changing how care is delivered.
Changes in federal and state regulations
surrounding telehealth and remote care are expanding access to care for tens of
millions of Americans.
Many of these expansions, for example the
changes in telehealth and Remote Patient Management billing for Medicare
beneficiaries, will remain in place after the emergency is over.
Language in the regulations expanding access
beyond just COVID-19 treatment means a broad swath of patients will access and
use some form of remote care in the next few months, and many more providers
will be practicing using telemedicine.
Fears and worries about standards of care,
patient acceptance, and financial viability will be put directly and obviously
to the test.
The opportunities for remote medicine go far
beyond video appointments. Creating a broad virtual health strategy that
includes asynchronous elements, remote monitoring, and patient reporting is
While many small providers and systems will use
consumer-level systems out of the need for convenience and speed, these are the
most likely parts of the exceptions to be temporary. CIOs and systems need to prepare
for what will remain usable after these changes are reversed.
2020 Reimbursement changes
prior to coronavirus
In 2019 and 2020, multiple new CPT
and HCPCS codes were publicized for remote and virtual care. CMS also removed
the geographic and originating site requirements for telehealth appointments
for Medicare Advantage patients, which represent nearly a third of the overall
Medicare population. For the balance of Medicare beneficiaries, those
requirements remained unchanged.
In response to the COVID-19 crisis,
Congress passed the Corona Preparedness and Response Supplemental
Appropriations Act on March 6th. Among other things, this allowed
the secretary of HHS to open these telehealth opportunities to the full
Medicare population. States have also acted, some through cost sharing waivers
or parity mandates. CMS is encouraging commercial payers to expand coverage,
offering waivers for payers to change their coverage options mid-year to expand
telehealth access. Most major commercial payers now support telehealth services
With patients reluctant to travel,
this expansion of reimbursement can be a lifeline for practices struggling with
the question of staying open versus staying safe. Major primary care and
internal medicine practices in Massachusetts are now expecting to temporarily transition
to entirely virtual and remote services. This has significant benefits for
patients, both those with COVID-19 symptoms and those struggling with other
health or wellness issues, as to date all federal announcements have been clear
that coverage expansions are for all needed care, not just that related to COVID-19.
It’s likely that this expansion of
services in Medicare would have happened eventually, but probably over several
years. This is the single change most likely to stay in place after the end of
Licensing and Provision of Care
On March 13th,
with authority granted by the Declaration of Emergency, CMS enacted waivers
allowing providers with a license in good standing to provide care to Medicare
beneficiaries anywhere in the United States. This was a landmark step, and
essential to opening access to telehealth and virtual care nationwide. These
changes allow for much truer load balancing across the national provider
population. Without them, providers in low professional density states could
easily become overwhelmed, even with the efficiencies or time savings offered
by telehealth and remote care. Many,
though not all, states have followed suit.
These limitations have been a significant obstacle to scaling telehealth and remote care deployments. The fact that direct telehealth does little by itself to save provider time is a major weakness of video appointments. Already, practices in Rhode Island, Washington, and Louisiana are reporting that the volume of virtual appointments that have been requested are overwhelming their providers. One Philadelphia system has reported a 10x growth in virtual appointments in a single week. As more patients are diverted to remote care and triage, these pressures will grow.
Systems need to be able to divert
non-urgent appointments and requests away from overwhelmed providers and
towards providers with more capacity. Expansions to the scope of practice for
Advanced Practitioners (AP) will allow Nurse Practitioners, Physician’s
Assistants, Advanced Practice Registered Nurses, and other APs to fully
contribute as demand grows. While some states have resisted these expansions of
licensure and practice scope, many others have adopted them even before
COVID-19, and these changes are likely to last.
HIPAA and Enforcement Discretion
OCR, the office within HHS that
monitors HIPAA privacy regulations, announced on Thursday, March 19th,
that they would exercise “enforcement discretion” over use of
non-HIPAA-compliant platforms for telehealth during the COVID-19 health
emergency. The care that can be offered is explicitly not limited to COVID-19
care, as “a covered health care provider may provide… telehealth services in
the exercise of their professional judgement to assess or treat any… medical
Not any video communication
platform is acceptable under the revised standards. The technology must be
“non-public facing,” meaning that live content or recordings cannot be
accessible by other users during or after an encounter. Examples included “Facebook
Live, Twitch, [and] TikTok.” Acceptable alternatives included Apple FaceTime,
Facebook Messenger, Google Hangouts, and Skype.
For small practices and organizations that did not have a telehealth solution in place, this is a critical step to allowing patients to continue to receive care, albeit from a safe distance. In conjunction with policies that are greatly expanding what visits can be provided, reimbursement for many remote appointments are at the same rate as in-person visits . This will provide smaller practices a potential lifeline to critically needed cash flow to stay open.
In the long term, however, these solutions aren’t enough. Non-compliant platforms will pose dangerous privacy and liability risks when the exceptions are rescinded. These HIPAA exceptions are the least likely to be retained long-term. Options that have a HIPAA-compliant option but are still restricted to video appointments, such as Zoom Health, are still lacking in other areas. Remote primary care and care for chronically ill patients requires that monitoring equipment be in place, along with systems for receiving and recording their data.
Considerations for the Future
The loosening of these constraints
allow health care providers and organizations to offer telehealth services
while patients are restrained from or unwilling to travel. Hopefully, these
changes to support telehealth alleviates the stress and burden on both
providers that see the patients and the organizations that need to have
patients seen to remain solvent. Telehealth through video chat is an excellent
tool, but the best clinical results and the most effective relief comes from
more than just remote appointments.
This article from
a group of hospital MDs in Bergamo, Italy gives invaluable perspective from
the center of a pandemic hotspot about what kinds of care changes are going to
be most helpful as the number of sick increases. They include increasing
outreach into the community and more effective and aggressive home care. That
includes monitoring and care delivery within the home for mildly ill patients
to reserve vital hospital resources for the most critical needs.
Video appointments will only be a
part of the solution, and so can only be a part of a fully featured remote care
platform. Announcements from the FDA that they are allowing vendors and users
of FDA-cleared devices to modify those devices for home monitoring will help.
It gives providers and the vendors supporting them much needed flexibility, and
the ability to respond to needs quickly with the equipment they have on hand.
The longer the crisis persists,
the more these exceptions will become a part of the new normal going forward.
Some, like looser HIPAA requirements, will almost certainly be rescinded. Changes
to reimbursement, to licensing, and even to scope of practice, represent the
acceleration of changes that were already underway and thus likely to stick.
Even outside of these regulatory
issues, however, we’re seeing a sea change in the use of telehealth. Patients
have been open to remote care for years. What they haven’t been able to do is readily
access it, especially with their primary care providers. However, COVID-19 has
forced the issue and now it is providers reaching out to their patients suggesting
a telehealth visit. Now that patients have been able to experience telehealth,
will this be the preferred visit modality going forward?
Provider trust, organizational
deployments, and the healthcare and business cases for it have been significant
barriers but the current situation is breaking those down. As patients get used
to telehealth and remote care and as providers and systems continue to make it
part of their standard provision of care, it’s hard to envision going back to
the status quo.
Telehealth and more broadly
virtual care has been a technology on the cusp of
“breaking out” for more than a decade now. COVID-19 is the spark that has
lit the telehealth fire, a fire that will not be going out anytime soon.
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