Interstate telehealth visits in jeopardy as pandemic licensure waivers expire

Temporary measures implemented by insurers and state governments during the COVID-19 pandemic have made it easier for patients to seek care from out-of-state clinicians via virtual care visits.

If and when those pandemic licensure flexibilities go away, it will impact different states to varying degrees while also influencing care delivery for both established patients and individuals in rural settings, a new study reveals.

“The widespread use of telehealth is often viewed as the silver lining for the COVID-19 pandemic,” the study’s authors reported in the June issue of Health Affairs. “As telehealth flexibilities expire, it will be important for policymakers to enact permanent telehealth policies in an evidence-based manner.”

In March 2020, the Centers for Medicare and Medicaid Services (CMS) allowed individual states to waive within-state licensure requirements for Medicare beneficiaries obtaining telehealth services. Around this time, all 50 U.S. states and Washington, D.C., passed licensure waivers, which permitted patients to access telehealth visits with out-of-state providers. Now, the authors noted, this provision remains active in only 15 states.

To evaluate the extent of interstate telehealth use by Medicare beneficiaries, Juan J. Andino, M.D., chief resident in urology, and co-authors from the University of Michigan analyzed a national sample of fee-for-service claims data from January 2017 through December 2020.

As a member of state and national health policy and advocacy groups, Andino told Fierce Healthcare that providers and professional associations “had strong opinions for or against interstate telehealth."

"But when we sought out data regarding how across-state telehealth has been delivered, we could not find anything," Andino said.

The University of Michigan researchers demonstrated that the volume of interstate telehealth use rose from about 17,000 services in the first quarter of 2020 to almost 100,000 services at the end of that year. But they pointed out that this form of care delivery remained a relatively small share of all outpatient and telehealth visits.

Out-of-state telehealth comprised 0.8% of all outpatient visits and 5% of all telehealth visits overall. For individual states, the proportion of out-of-state telehealth varied, ranging between 0.2% and 9.3% of all outpatient visits.

“Given that the future of the telehealth landscape remains to be determined as the current flexibilities are tied to the public health emergency, we felt it was very important to provide both national-level and state-level data on how interstate telehealth was used during the first year of the pandemic,” Andino said. 

Most out-of-state telehealth use was for established patient care. A greater proportion of rural patients—28%—used out-of-state telehealth, while 23% of rural patients did not receive care outside of their state at all.  

The authors indicated that their “analysis of trends in out-of-state telehealth use by Medicare beneficiaries yielded several findings that should inform policy discussion on interstate telehealth."

"First, our findings suggest that interstate telehealth legislation and policy changes are best prioritized at the individual state level," the study authors wrote.

Among their other findings, the authors observed that out-of-state telehealth visits are mainly used for continuity of care rather than the acquisition of new patients. In addition, a greater percentage of rural patients used both out-of-state in-person and telehealth services compared with their nonrural counterparts, although the authors could not explain the reason behind this trend. It remained unclear whether patient choice or clinician supply fueled the decision to obtain care from out-of-state providers.

In acknowledging their study’s limitations, the authors pointed out that the data set limited the ability to ascertain the physical location of the patient or physician at the time of the visit. Although they used the mailing addresses for the patient and clinician, this may have led them to under- or overcount out-of-state healthcare claims if a patient resided in another state.

The authors recommended that individual states continue to monitor trends in interstate telehealth, especially how rural patients are using interstate virtual care visits to better comprehend how to prioritize this issue in the future.

“We hope that this data can help direct conversations between lawmakers and providers more than theoretical fears or concerns,” Andino said.