Risks & Benefits of Telehealth: Controversy about Post-Pandemic Telehealth

While 2020 virtual health care policies during the public health emergency are starting to wane, more than 600 bills supporting new telehealth laws are currently pending at both the federal and state levels. Congressional measures largely support the expansion of telehealth access, especially in Medicare. The many benefits of telehealth have become quite obvious to many consumers and professionals alike.

Clients and patients have realized the many benefits of telehealth services, and depending on the study, 66 to 87% are stating preferences for telehealth over in-person care. See Harris Poll Shows 84% of US Patients Prefer Telehealth Appointments for recent survey details.

As a result of these and other factors, politicians from around the country are working on promoting telehealth to allow people the unique flexibilities offered by telehealth. Here’s an example:

Johanna just recently obtained a Lyme disease diagnosis, confirming her decade-long fears. She is fraught with Lyme-related arthritis and feels significant pain with every movement. She is distraught about her illness, as well as treatment and what this new diagnosis means for her as a 64 year-old-accountant. She is working with a rheumatologist who allows her to see him through telemedicine and has been seeing a teletherapist to help her transition her life to the new regimes needed. Without their flexibility in offering telehealth services, she would be unable to visit them weekly. 

During the early part of the COVID-19 pandemic, most telehealth visits became legal, thanks to governmental waivers and many other measures. To hasten the adoption of telehealth services, state and federal governments also changed policies that had previously created barriers to telehealth expansion, including:

• Healthcare practice across states with existing licenses 
• Limiting which professionals are allowed to offer care
• Requiring clients and patients to go to a designated healthcare site to receive telehealthcare
• Ability to charge the same rate for virtual visits as charged for in-person visits.

However, with the onset of COVID in the United States in March of 2020, the use of telehealth visits increased 154% in March 2020, as compared to the previous year. Telebehavioral health service delivery led the other professionals by more than two-fold. 

Telehealth Support in the Different States

A variety of telehealth-supportive measures were quickly passed in a number of states in 2020. While the following list is not exhaustive, it shows the breadth of issues being addressed by these new initiatives and the many telehealth benefits they hold for different stakeholders.

• At the beginning of 2021, Massachusetts passed a law that focused on equal insurance coverage of telemedicine treatment. The law includes treatment for primary care, behavioral health, and management of chronic diseases. The budget also allocated funds for outcomes research over the next two years.
• In Arkansas, a telemedicine bill was passed last month to provide better coverage for people in rural areas.
• California has passed a number of new bills and many more are being considered to make telehealth services permanently available and prohibiting insurance reimbursement rollbacks to pre-pandemic levels. (See TBHI’s States Taking Immediate Action to Prevent Payer Telehealth Coverage Rollbacks)
• Delaware, Georgia, Hawaii, Minnesota, and New Mexico have pay-parity laws against the telehealth coverage rollbacks already in effect

Major support for telehealth services has galvanized and focused on the already-technically advanced industry. The telehealth investor community invested more than $10 billion last year alone in telehealth start-ups. Yet, legislative change is creating uncertainty about telehealth’s projected rate of growth post-pandemic. Controversy has arisen about how the federal, as well as state governments, should move forward.

The Future of Telehealth: Differences of Opinion

The Biden administration states that they will leave COVID-pandemic-related emergency measures in place during all of 2021. See TBHI’s Public Health Emergency Extended through 2021. Yet more recently, a key government report about the pros and cons of telehealth was presented as testimony on May 19, 2021, before the Committee on Finance of the U.S. Senate. The Centers for Medicare and Medicaid Services (CMS) report was submitted by United States Government Accountability Office (GAO). The report was entitled Medicare and Medicaid COVID-19 Program Flexibilities and Considerations for Their Continuation. The report’s authors are Jessica Farb, Director, Health Care, and Carolyn L. Yocom, Director, Health Care.

To quote a summary of the report:

What GAO found In response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for overseeing Medicare and Medicaid, made widespread use of program waivers and other flexibilities to expand beneficiary access to care. Some preliminary information that is supportive of telehealth expansion is available on the effects of the telehealth waivers. On the positive side of continuing the expansion of telehealth, these findings are most relevant:

• Medicare. CMS issued over 200 waivers and cited some of their benefits in a January 2021 report. For example, CMS reported that:
• Expansion of hospital capacity. More than 100 new facilities were added through the waivers that permitted hospitals to provide care in non-hospital settings, including beneficiaries’ homes.
• Workforce expansion. Waivers and other flexibilities that relaxed certain provider enrollment requirements and allowed certain nonphysicians, such as nurse practitioners, to provide additional services expanded the provider workforce.
• Telehealth waivers. Utilization of telehealth services—certain services that are normally provided in-person but can also be provided using audio and audio-video technology—increased sharply. For example, utilization increased from a weekly average of about 325,000 services in mid-March to a peak at about 1.9 million in mid-April 2020. Medicaid. CMS approved more than 600 waivers or other flexibilities aimed at addressing obstacles to beneficiary care, provider availability, and program enrollment. GAO has reported certain flexibilities such as telehealth as critical in reducing obstacles to care.
• Examples of other flexibilities included:
• Forty-three states suspended fee-for-service prior authorizations, which help ensure compliance with coverage and payment rules before beneficiaries can obtain certain services.
• Fifty states and the District of Columbia waived certain provider screening and enrollment requirements, such as criminal background checks.

Given the above, many predictions favor Medicare as the most promising focus for clinicians who wish to grow their telehealth practices into the future. For a broader discussion of the many issues involved, see TBHI’s Future of Telehealth Reimbursement: Offering Medicare Telehealth Services?

Risks of Telehealth by Medicare and Medicaid

Although telehealth has become a reliable and supportive option for many in need of healthcare, the rate of expansion is variable across states, as some states are allowing insurance carriers to roll back telehealth benefits in an effort to return to the pre-pandemic healthcare system. For details, see TBHI’s States Taking Immediate Action to Prevent Payer Telehealth Coverage Rollbacks.

In Colorado and Pennsylvania for example, pandemic-era telehealth rules are expiring. As some conservative states move forward, some have also begun withdrawing the permission for out-of-state or international clinicians to provide care. The US Justice Department is also tallying the downside to telemedicine (i.e., the potential increase of fraud). Since October 2020, federal prosecutors charged approximately 86 criminal defendants with $4.5 billion in Medicare or Medicaid fraud. Many of these cases involved billing for equipment and tests and usually involve little or no interaction with patients. See the articles below for details:

• Telemedicine Fraud and the Department of Justice
• Unprecedented Healthcare Fraud Involves Telehealth Fraud 
• DOJ Telemedicine Fraud in Health Insurance Fraud “Takedown”

Adding to the negative side of the controversy, the full effect of telehealth services on cost, safety, and clinical outcomes hasn’t yet been fully determined. In the words of the GOA report, these issues are in need of attention:

• Increased spending. Telehealth waivers can increase spending in both programs if telehealth services are furnished in addition to in-person services.
• Program integrity. The suspension of some program safeguards has increased the risks of fraud, waste, and abuse that GAO previously noted in its High-Risk report series.
• Beneficiary health and safety. Although telehealth has enabled the safe provision of services, the quality of telehealth services has not been fully analyzed.

The Telehealth Expansion: Telehealth Controversy

Balanced reporting is expected in government documents such as the GOA report, as it is essential for properly positioning telehealth for decades and centuries to come. Meanwhile, practitioners may wish to take heart in that the pandemic forced a level of telehealth adoption that was unexpected. Now that consumers have had a year of the many benefits of augmenting or replacing in-person care with the ease and immediacy of telehealth, more than two-thirds have stated that they prefer telehealth to in-person care. Given the many benefits of telehealth for Medicare beneficiaries, Medicare seems to be offering the best path forward for growing one’s telehealth services.

What Are Your Thoughts?

Do you have examples of the risks or benefits of telehealth expansion? Perhaps you have other views?

Please comment below.