Temporary telehealth and remote patient monitoring (RPM) policy changes at the state and federal levels have generated new evidence, practices and adaptations which question the need for many of the restrictions that had been in place prior to the pandemic. Six months in, patients, policymakers, caregivers, clinicians and other providers are generally supportive of maintaining the expanded availability of telehealth services and see it as a critical tool in advancing a well-coordinated, patient-centered, and value-optimized health care system.
The Taskforce on Telehealth Policy (TTP) formed to assess early findings and experiences under the flexibilities granted by Congress and CMS during the public health emergency (PHE) and to build a consensus among diverse stakeholders on recommendations that will help realize telehealth’s potential to drive well-coordinated, patient-centered, and value-optimized care. These recommendations were also informed by more than 300 written public comments and a virtual townhall attended by nearly 1000 stakeholders. In the end, the TTP found substantial agreement for keeping most—but not all—of the COVID-19 policy changes and exploring new ways to harness the rapidly evolving possibilities of telehealth.
Policymakers put in place extensive restrictions on the use of telehealth at a time when technology was less mature and use cases for it were more limited than today. Prior to the pandemic, assumptions about patient safety, program integrity (fraud, waste and abuse), quality and cost were cited as reasons for these restrictions. The TTP believes that data collected during the COVID period should help inform a reevaluation of telehealth policy and utilization, particularly in fee-for-service (FFS) Medicare. The TTP also finds that the move to value-based payment models with shared financial risk and responsibility for improving the health of a population should alleviate many of the previous concerns, as they allow clinicians and patients to choose the care modalities most appropriate to their needs and preferences.
The TTP acknowledges there are many ways telehealth is used by medical practitioners and accessed by patients. Telehealth as part of an integrated approach with in-person primary care and chronic disease management is different from telehealth used for urgent care or triage, which is different from telehealth used by hospitals for post-discharge follow up. These are only some examples of the variation of telehealth usage. For purposes of this report, we discuss telehealth in a way that can apply to all of these practices.
The TTP broke into three subgroups: Patient Safety and Program Integrity; Data Flow, Care Coordination and Quality Measurement; and Effect on Total Cost of Care. Below is a summary of each group’s findings and the overall recommendations of the TTP, which are delineated more deeply in the pages to follow:
Patient Safety: Telehealth can enhance patient safety by preventing care delays, reducing exposure to pathogens, and minimizing travel needed for in-person care. Policymakers should fund research on telehealth best practices for patient safety and update existing patient safety event reporting structures to incorporate telehealth.
Program Integrity: Fraud occurs in all health care programs, but emerging artificial intelligence tools to audit claims and other data may have potential to make it easier to detect aberrations quickly. In the case of telehealth, investigators can uncover Internet Protocol (IP) addresses and other digital signatures (e.g. date/time stamps) to identify bad actors. Integrating these tools into existing enforcement mechanisms may eventually reduce telehealth program integrity risks below those involved with in-person care.
Quality: Telehealth is essentially a setting or modality of care, rather than a type of care. As such, it should be held to the same standards and quality measures as in-person care wherever possible and appropriate. In cases where the unique characteristics of telehealth dictate a change in a given measure, it should be adapted, rather than reinvented or developed from scratch. Where evidence and standards of care allow, measure stewards should do so without altering standards and expected outcomes for services provided via telehealth.
Rules and protocols for data sharing and care coordination between telehealth and other care sites, and their implementation in the form of telehealth certification requirements, should be developed in alignment with standards for other settings, and implemented in the form of telehealth platform certification requirements, with the goal of preventing telehealth from adding to the fragmentation and data silos that plague our healthcare ecosystem and maximizing the integration of virtual care.
As telehealth usage and digital connection continue to expand, patients and the entire healthcare ecosystem could benefit from tools that enhance care coordination and improve patient experience.
“Virtual medical homes” emphasizing remote care, closer patient monitoring and integration of telehealth with in-person care is one potential example, as electronic access to care is a facet of successful patient-centered medical homes. Advancing the concept of a living, digital document populated by all members of a patient’s care team that integrates information into a hub to support all care – virtual and otherwise – could also drive higher quality and better outcomes. Policymakers should prioritize pilot testing these concepts.
Telehealth is well-suited to improving the measurement of patients’ experience of care. The current mail-based surveys suffer from low response rates, the inability to reach specific patient populations and slow feedback loops. Policymakers should leverage telehealth’s digital aspects to improve timeliness, targeting, and engagement in assessing patient experience, which is an essential aspect of quality.
Effect on Total Cost of Care: Prior to the pandemic, there was little data available to assess or project the cost effect of widespread access to telehealth in a FFS environment, particularly in Medicare. The temporary lifting of previous restrictions during the PHE allows an opportunity to begin doing so, albeit under extraordinary circumstances. A fuller picture will require understanding the effect on costs of COVID-induced care avoidance – among other factors unique to the current situation- and how those interact with greater utilization of telehealth during the pandemic. However, data collected to date indicate that the virtually unfettered availability of telehealth has not resulted in excess cost or utilization increases, even as supply and demand for in-person care has rebounded.
Behavioral health has been an exception. The TTP found anecdotal and some data-driven evidence of significant increases in uptake of tele-behavioral health under the public health emergency. In part, the increase in demand may be related to the stresses and dislocation brought on by the pandemic, the lessening of social stigma some may attach to visiting in-person sites for this type of care, or the reduction in regulatory barriers. Increased utilization of behavioral health services has the potential to decrease net costs and improve outcomes, as untreated behavioral conditions can contribute to greater physical health needs and overall spending. Again, additional evaluation is needed to better understand the impact on outcomes.
Early evidence also suggests that the expansion of telehealth has helped drive a reduction in the rates at which patients missed appointments (no-shows), which has been demonstrated to increase care plan adherence, improve chronic disease management and yield downstream cost savings. It has also increased the use of transitional care management services that improve outcomes and reduce readmissions, mortality rates and costs. Finally, some skilled nursing facilities (SNFs) have deployed telehealth to resolve residents’ health issues that would otherwise have prompted much more costly ambulance trips to hospitals and emergency departments (EDs).
These data, while collected at a time of immense change and uncertainty, have not shown the large increases in net costs that some predicted broader access to telehealth services would bring. We won’t know the true effect until the pandemic is over or until care has been adapted to the new reality post-COVID. Future, permanent telehealth policy for public payers should be made on the basis of such available data and findings. As the volume of value-based payments increases across public programs, access to telehealth should also increase toward the level currently seen in the commercial market if these tools prove effective in providing high-quality care that meet patient and payer goals.
Overarching Telehealth Issues: Policymakers should take additional steps to support safe, effective and equitable integration of telehealth into our healthcare ecosystem. This includes establishing a uniform taxonomy describing the full range of telehealth services and modalities to aid in aligning standards, quality measurement, payment principles and program integrity guidelines. Policymakers must also promptly expand efforts to address deficiencies in broadband access and technology infrastructure, as well as trust and digital literacy. These gaps can increase health disparities and limit the dispersion of telehealth’s benefits. Finally, while the potential of telehealth to improve care and outcomes abounds, policymakers should not expect telehealth to singlehandedly resolve longstanding issues that exist throughout our healthcare system.
Policymakers should make permanent the following specific COVID-19 policy changes:
- Lifting geographic restrictions and limitations on originating sites.
- Allowing telehealth for various types of clinicians and conditions.
- Acknowledging, as many states now do, that telehealth visits can meet requirements for establishing a clinician/patient relationship if the encounter meets appropriate care standards or unless careful analysis demonstrates that, in specific situations, a previous in-person relationship is necessary.
- Eliminating unnecessary restrictions on telehealth across state lines.
Policymakers should look closely at the effect of expanding prescribing authority to telehealth, as authorized by the PHE. They should evaluate what policies and guidelines could be applied to virtual prescribing to ensure patient safety and avoid adverse outcomes.
Policymakers should fully reinstate enforcement of Health Insurance Portability and Accountability Act (HIPAA) patient privacy protections that was suspended at the start of the public health emergency.
The TTP thanks everyone who helped us gather information and data and shared comments to aid our work. We hope these findings and recommendations guide policymakers and other stakeholders to a future where we see telehealth as the natural evolution of healthcare into the digital age.