Health systems urge Congress to lay down a permanent road map for telehealth services as clock ticks on December deadline

A major House subcommittee is considering 15 bills to expand access to telehealth services as the clock ticks on a Dec. 31 deadline on pandemic-era flexibilities.

The American Telemedicine Association has referred to 2024 as the "Super Bowl" of telehealth regulation as the trade group pushes Congress to make permanent the Medicare telehealth flexibilities implemented during the COVID-19 pandemic.

"The looming deadline gives us a chance to examine long-term telehealth solutions that can drive innovation and health care through greater delivery," House Energy and Commerce Health Subcommittee Chair Brett Guthrie, R-Kentucky, said during a subcommittee hearing Wednesday. "A number of the bills make permanent a variety of COVID-era policies most notably permanently waiving originating site requirements as well as the policies expand the list of providers eligible to treat patients via telehealth."

Lawmakers are weighing whether to issue another short-term extension on telehealth flexibilities as they continue to evaluate cost and quality issues or to enact permanent changes to virtual care reimbursement.

Many health systems and providers urge lawmakers to move forward on permanent Medicare coverage for telehealth services to provide clarity and payment stability.

"Failing to make the COVID-era telehealth waivers permanent will result in a tragic loss of access to care for Medicare beneficiaries," Lee Schwamm, M.D., senior vice president and chief digital health officer at Yale New Haven Health System, testified during the hearing.

"So often, we give lip service to providing patient-centered care but rarely do we deliver on that promise. Telehealth allows us to do that, especially when a medical condition or social circumstance makes travel to the doctor's office, a physical, emotional or financial ordeal," Schwamm, who also is an associate dean for digital strategy and transformation at Yale School of Medicine, told lawmakers.

Prior to the pandemic, telehealth was mostly a cash-only service out of reach for most vulnerable populations and often used to deliver isolated and episodic care for low-complexity conditions, he noted.

Where Medicare leads, commercial insurers tend to follow. "Elimination of the waivers will have a profound ripple effect across the healthcare ecosystem, especially for vulnerable populations," Schwamm said.

In the past four years, health systems and providers have made deep investments in virtual care capabilities, with telehealth and in-person care now "deeply integrated and intertwined in routine healthcare delivery," Schwamm told lawmakers.

"Due to congressional inaction, telehealth's uncertain future continues to have a chilling effect on the healthcare ecosystem," he said.

Hybrid care that incorporates both virtual and in-person options has become a new standard of care, said Eve Cunningham, M.D., group vice president and chief of virtual care and digital health at Renton, Washington-based Providence health system.

"Patients aren't tracking on an extension; patients expect this model of care. We need permanency in our ability to deliver this type of care. In addition, for health systems when we build out some of these programs, for example, hospital at home, remote patient monitoring, tele-physical therapy or other types of broad programs we want to grow, there is an investment involved and when you have uncertainty as to whether or not there will be permanency in reimbursement you are going to be hesitant to make the investments to build that out," Cunningham told lawmakers Wednesday.

Telehealth has become an integrated part of Providence's care delivery system, she noted, making up about 20% of ambulatory care visits. Telehealth services are deployed across 93 acute care hospitals, including 42 hospitals from other health systems, and two high schools, with more than 1.2 million telehealth visits annually, according to her testimony.

"Telehealth is no longer a nice to have, but a core function of our healthcare delivery," Cunningham said.

She added, "Telehealth expands access to high-quality, coordinated care to more people in more places. Telehealth enables us to offer specialty services in remote and rural areas like Kodiak, Alaska, while also allowing us to care for underserved communities in urban areas like Los Angeles," she said.

Virtual care services also can help address the severe workforce shortage and clinician burnout issues facing health systems by creating flexibility in scheduling and care provider location, executives said.

Providence, like many other health systems, supports the CONNECT for Health Act and the Telehealth Modernization Act, two pieces of purpose legislation that would make many telehealth flexibilities permanent.

"When we don’t have permanency in telehealth reimbursement, it stifles the innovation, it stifles the ability for us to be able to really scale out and grow some of these programs," Cunningham said.

The CONNECT for Health Act would permanently remove telehealth geographic restrictions and expand originating site locations to include the patient’s home and remove requirements for in-person visits for behavioral health treatment. It would also allow rural health clinics and Federally Qualified Health Centers to serve as distant sites.

The Telehealth Modernization Act would permanently remove geographic originating site restrictions, expand the types of providers eligible to provide telehealth services and extend coverage for audio-only telehealth, among other telehealth flexibilities.

The American Hospital Association (AHA) is among the industry groups pushing Congress to make key telehealth flexibilities permanent before they expire on Dec. 31, 2024. "Given current healthcare challenges, including major clinician shortages nationwide, telehealth holds tremendous potential to leverage geographically dispersed provider capacity to support patient demand," the AHA wrote in a statement submitted to the House Energy and Commerce Subcommittee on Health.

Lawmakers are weighing these legislative moves as they debate issues around cost and quality as well as the risks of fraud and abuse.

On the latter issue, a 2022 report from the Department of Health and Human Services’ Office of Inspector General (OIG) suggested that telehealth fraud was rare in Medicare during the COVID-19 pandemic. OIG looked at 742,000 providers that billed for a telehealth visit between March 1, 2020, and Feb. 28, 2021. More than 28 million beneficiaries, about 2 in 5, used telehealth services during that time. OIG identified 1,714 providers whose billing for telehealth services posed a high risk.

"It appears that telehealth can be used to deliver care without actually raising those serious concerns," Guthrie said during the hearing.

Regulators, lawmakers and researchers also continue to study whether telehealth services increase cost and utilization. Concerns that telehealth will drive up healthcare costs are a key impediment to its permanent expansion. There is ongoing debate about whether virtual care is a substitute for in-person care or an additive.

A previous telehealth extension was estimated by the Congressional Budget Office to increase Medicare costs by more than $2 billion, Guthrie noted during the hearing. "Making these authorities permanent is likely to cost more than a short-term extension. We want to make sure that whatever we move out of the committee is paid for and is delivering the best value for seniors," he said.

Research shows that telehealth increases spending, said Ateev Mehrotra, M.D., a Harvard professor of healthcare policy and medicine who has conducted extensive research on the impact of telehealth. 

But, the question of whether telehealth saves money is the wrong angle, he noted in his testimony. Policymakers should instead formulate their policy decisions based on the value of telehealth services.

"In my own research, we find that greater telemedicine use does lead to more visits, as well as improvements in chronic disease, medication adherence and fewer emergency department visits. However, these improvements do come at a cost. We estimate the greater telemedicine use is associated with a 1% to 2% increase in overall healthcare spending in the Medicare program," Mehrotra, a hospitalist at Beth Israel Deaconess Medical Center, testified Wednesday.

"Based on these findings, I urge Congress to permanently eliminate site location requirements and allow video visits for all conditions at any site. While telemedicine does increase spending, the increase is modest, and is associated with improvements in access and quality," he said.

Contrary to many other providers who advocate for payment parity with in-person care, Mehrotra believes telehealth visits should be reimbursed at a lower rate than in-person visits. "Payments for care and Medicare are based on the time a clinician takes to provide that care and the associated space staff and equipment. If something costs less, we should be paid less," he said Wednesday.

He added, "I do not think Medicare should cross-subsidize in-person visits with telehealth visits because will create distortions in the market. It will give virtual-only companies, many of those funded by private equity, an unnecessary competitive advantage and will also incentivize clinicians to give up their physical practice."

Mehrotra also urged regulators to closely monitor virtual-only companies to ensure they provide high-quality care services.

Payment parity continues to be a key issue in the discussions around Medicare telehealth policy. Providence's Cunningham pushed back on the idea that telehealth services require less investment from providers.

"Just because we're offering visits virtually does not mean that we have a significant change in our overhead costs. We still have to pay all of our overhead regardless of whether or not we're doing a mix or a hybrid of in-person and virtual care. And in addition, for virtual care, there are expenses that need to be considered. There are expenses involved in standing up programs, the implementation, the workflow redesign, the change management, license credentialing, ensuring that you have billing and compliance and administrative costs as well," she told lawmakers.

Schwamm said setting a much lower reimbursement rate for virtual care could discourage the use of telehealth services.

"Providers simply can't take a 50% pay cut when they could be seeing an in-person patient at full rates. Remember, we have unmet demand, my office could be filled with patients from now until the cows come home," Schwamm said. "I think we have to recognize that we have to tie it to the true cost of providing the visit. Right now the cost is actually higher, because we have to make full in-person capability and telehealth capability."

He added, "If we have a permanent road map, we can start to actually readjust the expense base and figure out ways to deliver telehealth at lower cost. I would be in favor of a ramp that would take us from full parity down to a lesser value. But, we need to study very carefully where that price point is so that it balances utilization rather than creates perverse incentives."

Fred Riccardi, president of the Medicare Rights Center, a national consumer service organization, advocated for greater oversight of telehealth service before permanently expanding Medicare coverage.

"There is still much we don't fully understand, including how various services are working for beneficiaries, whether they are high quality or their impact on health care disparities and what we do know suggests room for improvement," he testified. "We believe that continuing the pandemic-era system without adjustments to incorporate lessons learned, such as the need for additional data oversight and beneficiary protections, would be a missed opportunity."

The organization recommends prioritizing telehealth policies that meaningfully increase access, promote health equity, include robust consumer protections and drive high-quality care.