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Bipartisan Policy Center Report Highlights Telehealth Policy Considerations


November 01, 2022

Last month, the Bipartisan Policy Center (BPC) released a comprehensive report on The Future of Telehealth After COVID-19. The report is based upon an analysis of Medicare Telehealth Utilization and Spending Impacts 2019-2021, stakeholder input and interviews, a literature review, and a national consumer survey. The BPC report examines the impact of increased access to telehealth during the pandemic and makes recommendations to policymakers on which COVID-19 policy expansions should be maintained post-public health emergency (PHE). Ultimately, BPC urges the federal government to extend emergency flexibilities for two years to preserve access while further evaluating telehealth effectiveness.

In its analysis, BPC made a number of key findings showcasing telehealth’s ability to alleviate access barriers for Medicare beneficiaries, address inequities in access and outcomes for racial and ethnic minorities, low-income earners, and individuals with chronic conditions, as well as improve patient continuity of care. The report also noted that patients and providers generally feel satisfied with telehealth services. Other findings include:

A decrease in telehealth utilization since initial pandemic peaks, although 2021 rates remained nearly 40 times higher than pre-pandemic telehealth visits
Most telehealth visits were for primary care visits and 44% of all behavioral health visits in 2021 occurred via telehealth
About 1 out of 5 telehealth visits were audio-only in 2021
Telehealth utilization was higher in urban areas and for non-white beneficiaries
Beneficiaries with disabilities and dually eligible for Medicare and Medicaid were more likely to use telehealth in 2021
Medicare spending on telehealth remains a small percent of overall spending – for the outpatient codes
BPC examined, telehealth spending was between 1.5% and 3.3% of total spending in 2020 and 2021

In applying its findings to policy recommendations, BPC discusses an attempt to balance competing goals, for instance the need to increase access to care against the need to ensure quality and cost-effectiveness. The report also highlights areas to focus future research and notes the need to examine telehealth outside of PHE conditions to truly generalize findings. In addition, BPC acknowledges limitations in its spending analysis that don’t factor in the potential reduction in long-term costs related to emergency room visits in correlation to increased telehealth visits.

In addition to extending Medicare telehealth flexibilities for two years, key BPC recommendations to Congress and the Biden administration include:

Maintain access to telehealth for Medicare beneficiaries regardless of location or medical diagnosis – including the home/patient location as an authorized originating site and removing geographic limitations (with protections to require providers to see patients in-person or refer to in-person care when necessary)

Authorize FQHCs/RHCs to permanently serve as distant site providers

Continue access to primary care and behavioral health services with minor adjustments post-PHE (the recommendation notes that if further research supports it, CMS could consider limiting certain services to existing patient-provider relationships – except in rural areas and for alternative payment methodology (APM) providers)

Continue audio-only coverage and incorporate audio-only into telehealth definition (post-PHE audio-only restrictions should limit coverage to established patients and at patient request)

Permanently expand asynchronous services beyond virtual check-ins and Alaska and Hawaii demonstration projects for both new and established patients

Make Health and Human Services (HHS) 1135 temporary waiver authority permanent for future PHEs

Eliminate the requirement for in-person visits for telemental health services (BPC states this is an undue burden on those who cannot access behavioral health providers in-person)

Require evaluation of controlled substance prescribing via telehealth and for non-hospice, non-cancer patients, first require an in-person exam prior to prescribing substances prone to abuse (BPC additionally recommends the Department of Justice (DOJ) follow through on its requirement to create a special telemedicine registration process to allow for certain in-person requirement exemptions)

Refine reimbursement rates and end broad payment parity between telehealth and in-person care to offset any cost/utilization increases, including implementing different rates for audio-only and video visits

In regard to transparency and consumer protections in particular, the report also recommends clear information to beneficiaries be provided regarding benefits appropriately delivered by telehealth and ensuring that beneficiaries consent to the use of telehealth. BPC additionally recommends the ability to distinguish between traditional and fully virtual providers be determined, and that enforcement resume related to HIPAA. In regard to fraud, waste, and abuse protections, the report calls for sufficient funding to the HHS Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) to modernize and track telehealth use, the requiring of outlier provider audits, and that high-cost durable medical equipment (DME) and laboratory tests be limited to established patients, unless providers are part of APMs. To improve data quality, the BPC suggests CMS simplify telehealth billing and develop additional guidance for providers to ensure uniformity and coding accuracy. Lastly, the BPC recommends requiring MedPAC complete a formal evaluation of post-PHE telehealth impacts on access, quality, patient outcomes, and cost to truly determine long-term trends and policies.

BPC’s report is extremely thorough and highlights the many issues policymakers are facing in contemplating permanent telehealth policies. Some of BPC’s attempts to balance recommendations and exceptions to address concerns raise additional complexities behind the considerations further showcasing where policymakers and future research should focus. For instance, in terms of audio-only, BPC notes that continued coverage is critical for beneficiaries lacking broadband and technology access, although additional restrictions should be adopted to address concerns related to quality and potential for overuse. However, policymakers should consider whether these additional restrictions may ultimately limit the access the report describes as critical. In terms of payment parity, BPC notes that it has been an important tool to increase access to care and ensure that practitioners provide telehealth services. However, given payer and policymaker concerns, BPC recommends that perhaps the best post-PHE policy would be to cover certain telehealth services at higher rates than pre-PHE rates, but not necessarily equivalent to in-person rates. That may go against other recommendations in the BPC report to simplify telehealth billing, although ultimately BPC does state that CMS should look carefully at cost differentials when determining appropriate rates. Since many providers state that the cost and time of providing services via telehealth and in-person are equivalent it is important that researchers and policymakers look carefully at that issue. In addition, BPC suggests that different reimbursement rates may ensure access to in-person services, yet also states that parity in rates ensures access to telehealth services, showing the difficulty in sufficiently balancing these various considerations. Researchers and policymakers must pay careful attention to all perspectives and data around these issues in order to truly ensure telehealth’s ability to increase access to necessary health care.

For additional details on BPC’s findings and recommendations, please view the report in its entirety.

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