Payers have lowered barriers to telehealth. Will those changes stick? Here's what experts have to say

In response to the COVID-19 pandemic, the Trump administration has opened up access to telehealth with sweeping—but temporary—changes to reimbursement policies.

In a matter of weeks, most of the barriers to telehealth reimbursement fell away enabling many of the changes that provider groups have wanted for years: payment parity for virtual visits, the ability to provide telehealth to patients at home, and allowing more providers to offer telehealth visits.

As of March 30, the Centers for Medicare and Medicaid Services (CMS) is now allowing more than 80 additional services through telehealth.

"These changes are significant not only for the 15% of the population that receives healthcare coverage through Medicare but to the U.S. population at large," said Jacqueline Marks, manager at Manatt Health, during a recent FierceHealthcare virtual event.

Medicare is often considered the pace car for telehealth and other healthcare policy, she said.

"State Medicaid and other payers model their telehealth policy approaches off what Medicare does. Changes to the Medicare program have a ripple effect through the rest of the healthcare coverage landscape," she said.

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State Medicaid programs followed suit, making major temporary policy changes such as offering out-of-state licensure flexibilities. Commercial payers also have responded by waiving patient cost-sharing.

In March, the HHS Office for Civil Rights also announced temporary flexibilities to enable providers to use common virtual platforms like Skype and FaceTime to do telehealth visits, which are not HIPAA compliant. OCR said it would waive potential penalties for HIPAA violations against healthcare providers that serve patients using these apps during the COVID-19 pandemic.

While physicians groups cheered these changes, they also worry that many regulations currently relaxed for the pandemic might tighten up again, which will reduce payer coverage for telehealth. 

"We are concerned about what will happen post-COVID if changes prevent us from providing telehealth at patients' homes as an outreach site," said Kerry Palakanis, executive director, Connect Care operations at Salt Lake City-based Intermountain Healthcare.

Before the surge in COVID-19 cases in March, the health system struggled to get healthcare providers engaged in video visits, Palakanis said during the virtual event.

In March and April, Intermountain conducted about 50,000 virtual visits a week, a huge jump compared to about 100 a month before COVID-19, she said.

"Video visits have become very commonplace and accepted within our system. We are finding patients absolutely love video visits," Palakanis said.

It's likely many of the changes made by the federal government, Medicare, state Medicaid programs, and commercial payers will stay in place, according to Marks.

The policy changes most likely to persist are payment parity, new types of telehealth services and eligible providers, telephonic visits, and home as an eligible originating site, she said.

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However, out-of-state licensure flexibilities will likely roll back when the COVID-19 pandemic ends, she said.

Also, don't count on HHS to keep in place temporary privacy and security flexibilities, such as the HIPAA technology rule.

"OCR is unlikely to extend HIPAA exceptions. When the emergency is over, you will no longer able to use Facetime, Skype and you must use a HIPAA compliant platform," said Krista Drobac, executive director of the Alliance for Connected Care, also a speaker during the webinar.

In many cases, Congressional action is needed to make Medicare reimbursement telehealth policy changes permanent, Drobac said.

"The types of practitioners who can provide telehealth also needs to be legislated," she said, noting that expansions were granted by CMS under its emergency authority.

Congressional legislation also is needed to help prevent fraud and abuse with the expanded use of telehealth. "Right now, we're operating with no fraud and abuse guard rails," Drobac said.

For policy changes enacted by HHS, the agency doesn't have a lot of authority to make these changes permanent, according to Drobac.

"They have been acting using new Congressional authority. They have expanded the number of codes that can be reimbursed and they can maintain those changes," she said.

Other federal agencies also would need to take action to ensure that temporary changes granted during the COVID pandemic become permanent policies. 

For example, the Drug Enforcement Agency is temporarily giving providers the ability to prescribe controlled substances via telehealth for behavioral health patients. Many providers would like to see that change stay in place but the DEA will need to take action to do so.

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State governments also need to address their temporary policy changes for out-of-state licensure flexibilities, Drobac said.

Healthcare stakeholders shouldn't assume these reimbursement policy changes will become permanent even as telehealth has proven to be a valuable tool during the pandemic.

"What it’s going to take to make this permanent is a lot of work," she said. "It's going to take a lot of stakeholder coordination."

In the past, one barrier to expanding telehealth access under Medicare was the lack of data proving its worth as patient adoption was low, Drobac said. With the spike in telehealth usage, policy leaders now have the data to make their case to Congress.

"We’re going to need to have some sound arguments on Congressional Budget Office scoring, like how much money this is going to cost the federal government. We’re also going to need patients to speak up and we need good data from this period," Drobac said.

She added, "All of this is needed to change Congressional minds for the long term."