Rural Providers Weigh Telehealth Investment Against Regulatory Uncertainty Holly Vossel June 8, 2022 Hospices are leveraging expanded telehealth options to maximize access for hard-to-reach rural patients despite lingering regulatory uncertainties. Case in point, the Providence Institute for Human Caring last year launched a tele-palliative care program aimed at addressing rural patients’ unmet needs. Thus far, the initiative has yielded positive results, but the process hasn’t always been easy, according to Dr. Gregg VandeKieft, executive medical director of the institute’s Palliative Practice Group. Snags along the way included dairy cows blocking staff from reaching patients. “For the first time we’re able to offer equitable access to specialty palliative care services for patients who need and want them in this rural setting,” VandeKieft told local news. “But we often have to balance providing health care with the time schedules and welfare of livestock, crops and other realities of rural living.” Washington-based Providence Health System provides a range of facility- and home-based care, including senior services and hospice. The company has more than 119,000 employees serving communities in six states. The TelePC program has increased care collaboration between Providence and the patients’ other providers, including family caregivers. It has also reduced travel time for the palliative care team and curbed unnecessary patient transfers and recurring hospitalizations. Hospice and palliative care providers have wrangled for decades with obstacles that complicate access to rural patients and make their care more expensive. For starters, rural regions are less likely to have a Medicare-certified hospice than urban counties. The service areas of the nearest hospices may not extend far enough to reach some of the people in those zones. When rural patients do have a provider in range, those hospices do their best to deliver care while contending with lower patient volumes, a smaller labor pool, long-travel times between home visits and the resulting travel costs. Some of the challenges are very unique to rural areas, like livestock schedules, lack of nearby caregiver support and limited internet bandwidth capacity. Telehealth has been an important part of improving providers’ ability to reach rural patient populations, according to Dr. Michael Fratkin, chief medical officer for ResolutionCare, a Vynca company. Fratkin founded palliative care provider ResolutionCare in 2015. Advanced care planning technology company Vynca acquired the company last year in its first move into the clinical care space. The pressures on rural providers go beyond the logistical. A successful tele-palliative care program requires not only greater access to high-speed internet in those areas, but also the confidence of the people they serve. Many rural residents place a lower value on telehealth services compared to the in-person care they are used to, said Fratkin. “The advantages of telehealth are the gain of seeing people at home and instantaneously sharing space with them,” Fratkin told Hospice News. “We are not physically entering their private space, not requiring them or staff to drive. What’s most important is creating that safe space to share. There are biases that virtual care is second rate. We have to blast through these biases. They are a bigger barrier to palliative and hospice care than dairy cows.” Then came the pandemic, and with it broad expansion of how providers can use telehealth — at least for the time being. Rapid deployment of telemedicine during the COVID-19 public health emergency (PHE) has created “a new pathway” for bringing palliative and hospice care specialists to rural areas, according to authors of a recent report published in the JAMA Health Forum. Additional studies further support the claim that changes to telehealth policy improved access. But without further regulatory or legislative action, those pathways will close when the federally declared emergency ends. The U.S. Department of Health & Human Services (HHS) most recently extended the PHE period to expire in July. The agency has not indicated whether or not they will renew it. As hospices navigate how they will use telehealth in the long-term, these uncertainties put them in a bind. Many are trying to weigh the benefits of telehealth investments against the possibility that they may soon have to shut down or cut back those programs. One factor policymakers might need to consider is that people may now expect that these services will remain available to them. The events of the past two years have opened the eyes of many patients to telehealth’s potential , according to Fratkin. “The pandemic telehealth experiment is unmeasured, but what we’ve discovered by being thrust into this experiment is that I don’t think patients want to give it up,” Fratkin told Hospice News. “They discovered the value of communications technology allowing them to stay in their lives and not interrupt care. Some of these providers are running back to the status quo as if it was working, but we’re going forward, not backward in this.” < Previous News Next News >

Libraries Add Telehealth to the Rural Communities They Serve Mari Herreras October 20, 2022 In the early days of the Covid pandemic, Dianne Connery realized something needed to be done for people in her rural Texas community to help connect folks to their medical appointments. Connery, director of the Pottsboro Area Library in Pottsboro, Texas, said it started when one woman with pulmonary disease came to the library for help, desperate to meet with her doctor but too high risk to come to his office—a two-hour drive south to Dallas. “Libraries are such perfect places for this because often we have the fastest internet in town, and we are used to helping people with technology,” Connery said. Connery and her fellow librarians sprang into action—creating a private space in Connery’s office with her laptop that had a camera. That gesture allowed the woman to meet with her doctor and go over recent MRI results. “I had never lived in a rural town until 2010 and didn’t realize how hard it is to access digital technology. You need a solid infrastructure for robust internet. Rural communities like ours don’t have that,” she said. From that first telehealth appointment in Connery’s office grew the library’s telehealth program that’s received national recognition. However, it never would have happened without Connery, with support from the town council, having fiber installed to support a teen eSports program long before the start of the pandemic. More community members used Connery’s office those early telehealth appointments, but through a National Library of Medicine grant and a community appeal, she was able to create a private appointment space from an old junk room and purchase the needed hardware and equipment. The next step was a unique partnership she developed with the University of North Texas Health Sciences Center to pair patients with the medical providers they needed. People can be seen two days a week for those using Medicare and Medicaid. Another day of the week is reserved for behavioral health appointments and another day is reserved for folks seeing their regular health providers. Connery’s work on the telehealth program doesn’t end there. The American Heart Association recently provided her library with blood pressure kits members of the community can check out. They also received a grant to hire a community health care worker to do outreach and education at the library and community spaces like the American Legion and the VFW. Now she’s focused on developing a digital literacy curriculum with the help of a three-year grant that helped her hire a digital navigator. Connery said she’s excited to see other rural libraries in Texas start telehealth programs but hopes more funding loops back to libraries desperate for increases in their own budgets. Connery is part of a national consortium of libraries who meet monthly to discuss telehealth programming—a growing interest in other rural communities beyond her Texas borders. Last month, a new telehealth program recently launched at two rural Pima County Library branches in Ajo and Arivaca—the first of its kind in Arizona—allowing folks with transportation or internet issues access to their doctors without having to drive several hours across the desert to nearby Tucson. “A huge sense of relief,” is how one Ajo resident recently described her experience that helped her connect with her primary care doctor in Tucson about worrisome symptoms she experienced after recovering from Covid. At the Salazar-Ajo Library she was able to collect the vitals her doctor needed using equipment provided by the library. And in the privacy of the library’s meeting room, she met with her doctor via a laptop and the internet provided by the library to go over her symptoms and vitals. “Being able to take my vitals and provide those to my doctor seems really important,” the Ajo resident said. “… while I was on my call with her, she had me do my vitals. We started with the blood pressure cuff, and how to apply it. Then my oxygen with the pulse rate oximeter.” The end of the appointment her doctor determined that the symptoms were not uncommon for someone who has had Covid, allowing the Ajo resident some relief and a better understanding of her recovery. Daniela Buchberger, Pima County Library’s Ajo branch managing librarian, said the new program, Health Connect, provides a private room for telehealth medical appointments. Inside is a laptop with a camera and equipment needed for a patient to take their own vitals: a digital scale, a thermometer, a blood pressure cuff, and a pulse rate oximeter. A patient will need to have the link provided by their doctor, usually via email. Library staff, due to privacy restrictions, aren’t going to be able to help someone log-on or use the equipment although the patient can bring someone with them to their appointment in the study room. Each library has written instructions on laminated cards as well as easy-to-follow visuals to help guide their experience. According to the Pima County Library, Health Connect is made possible by the Arizona State Library, Archives, and Public Records, a division of the Secretary of State, with federal funds from the Institute of Museum and Library Services. It is a joint effort between the Library, Pima County Health Department, University of Arizona’s College of Nursing, the Arizona Telemedicine Program, and United Community Health Care. "Access to telehealth is essential for people to get the care they need when traveling to an in-person visit isn't possible,” said Ken Zambos, program manager for Workforce and Economic Development in Pima County. “By providing this service, the library is providing access to equipment that transforms healthcare delivery and positively affects healthcare outcomes." Buchberger said a library card isn’t needed to use the room. However, reservations are needed and available in hour and half increments. Each person using a room is expected to clean all equipment after use with alcohol wipes provided. A fan in the room will be used to provide white noise to help with privacy as much as possible. “We may not have as much traffic as other libraries, but we are an important part of the community. The library is free, so is the internet,” Buchberger said. “Not everyone here has a car or a computer, but they have us.” About the Author Mari Herreras is the newest member of the Arizona Telemedicine Program and Southwest Telehealth Resource Center teams, serving as Communications Manager. She has worked in marketing and communications in publishing and nonprofits, as well as an award-winning journalism career for community and alternative newsweeklies in Tucson, Los Angeles, Seattle, and Wenatchee, Washington. See original article: https://southwesttrc.org/blog/2022/libraries-add-telehealth-rural-communities-they-serve < Previous News Next News >

Digital Health Tools Transforming Pediatric Telemedicine, Teletherapy & Telehealth Dr. Maheu February 24, 2022 The COVID-19 pandemic has led to an unprecedented rise in pediatric telemedicine to alleviate the strain of behavioral health issues. Unprecedented stressors abound. Children are now more often confined to their homes and are less able to socialize. They may be forced to adjust to their parents’ working from home. They may witness economic and emotional fluctuations that leave them more anxious than at any time in recent history. With the increased demand for care with a shortage of available pediatric behavioral professionals, many organizations have shifted to pediatric telemedicine and telehealth or teletherapy tools.. COVID 19 and Challenges for Pediatric Telemedicine for Behavioral Health A meta-analysis published in JAMA Network, pediatrics found that one in every four children suffered depression during the COVID-19 lockdown and the anxiety prevalence rate was 20.5%. According to the Centers for Disease Control and Prevention (CDC), compared to 2019, the number of mental health-related emergency visits in 2020 went up by 24% for children in the 5-11 age group and 31% in the 12-17 age group. The American Association of Pediatrics and the American Association of Child and Adolescent Psychiatry have officially declared an emergency as pediatric behavioral health went through a crisis countrywide. Parents had pretty tough times getting support for pediatric behavioral health following the closure of clinics and shortage of pediatric-trained therapists. Digital health tools primarily developed for adult health care have been adapted to connect parents to trained child therapists to overcome geographical and pandemic-related barriers. Full article here: https://telehealth.org/pediatric-telemedicine-2/?smclient=f760e669-8538-11ec-83c8-18cf24ce389f&smconv=5bc4c379-a4c1-484f-a411-33ec93777504&smlid=12&utm_source=salesmanago&utm_medium=email&utm_campaign=default < Previous News Next News >

Amazon Healthcare Building a National Telehealth Business Dr. Maheu, Telehealt.org January 2021 Amazon Care recently announced that it will expand nationally to all Amazon workers and other interested companies across the country in the summer of 2021. Amazon, the $1.6 trillion shipping giant, is launching a new service to provide essential medical services through Amazon Healthcare as a national telehealth business. Amazon Care uses an app that allows consumers to connect with doctors, nurse practitioners, and nurses virtually, 24 hours a day, via in-app chat or video. Initially launched and tested with Washington-based employees, Amazon Care recently announced that it will expand nationally to all Amazon workers and other interested companies across the country in the summer of 2021. “Making this available to other employers is a big step,” Amazon Care Director Kristen Helton said. “It’s an opportunity for other forward-thinking employers to offer a service that helps bring high-quality care, convenience and peace of mind.” Notice the last three descriptors: “high-quality care, convenience and peace of mind.” From the perspective of many healthcare providers, healthcare in the US has been lacking in each of these three areas. For employers registering for the service, which has partnered with Care Medical, employees near their headquarters will get online and in-person doctor visits. Employees elsewhere will get just the virtual components. Through Care Medical, Amazon Care currently offers an app to connect employees to a medical professional for a video consultation. It also offers follow-up care in the home for patients. The goal is to lower healthcare costs internally for Amazon and externally for some of the world’s most influential companies, using telehealth to meet people on their terms, with good care, wherever they are. Amazon’s Multi-Layered Business Strategy Anyone watching Amazon over the last year will be well acquainted with its accelerating moves to provide the early inklings of healthcare. Early Amazon Healthcare efforts were announced by Telehealth.org’s Telehealth News on 6/4/2020. In that article, it was reported that Amazon Health announced a pilot program offering virtual medical services to employees and their families. Amazon then expanded the presence of Alexa voice assistant, announcing that it was making it possible for voice assistant developers to offer HIPAA-compliant services for the Alexa platform. Amazon Pharmacy, a drug-delivering business in 48 states with steep discounts for Prime members was also released in November of 2020. Most recently Amazon has launched another offering called Amazon HealthLake, a HIPAA-compliant service that allows healthcare providers, health insurance companies, and pharmaceutical companies to store, transform, and analyze health data at a petabyte scale. As described on the Amazon HealthLake website: Amazon HealthLake removes the heavy lifting of organizing, indexing, and structuring patient information to provide a complete view of the health of individual patients and entire patient populations in a secure, compliant, and auditable manner. Using the HealthLake APIs, healthcare organizations can easily copy health data in the Fast Healthcare Interoperability Resources (FHIR) industry standard format from on-premises systems to a secure data lake in the cloud. HealthLake transforms unstructured data using specialized machine learning models, like natural language processing, to automatically extract meaningful medical information from the data and provides powerful query and search capabilities. Organizations can use advanced analytics and ML models, such as Amazon QuickSight and Amazon SageMaker to analyze and understand relationships, identify trends, and make predictions from the newly normalized and structured data. From early detection of disease to population health trends, organizations can use Amazon HealthLake to conduct clinical data analysis powered by machine learning to improve care and reduce costs. < Previous News Next News >

Report: Telehealth Programs Increase Workload for Nurses and Support Staff Katie Adams December 20, 2022 Many providers think their telehealth program increases the workload for nurses and support staff, according to a recent report. In 2023, hospitals and physician practices will have to focus on making their telehealth workflows more efficient, which may involve partnering with third-party administrators. Telehealth isn’t as widely utilized as it was at the dawn of the pandemic, but the care modality is definitely here to stay. However, many providers believe their telehealth program increases the workload for nurses and support staff, according to a recent report from research firm Sage Growth Partners. Providers also said they don’t think physicians enjoy using telehealth visits to treat patients. In 2023, hospitals and physician practices will have to focus on making their telehealth workflows more efficient, which may involve partnering with third-party administrators, the report said. In September, Sage Growth Partners surveyed 95 health system executives and 75 leaders of physician practices. Practices with fewer than five physicians were excluded from the survey. Most respondents said that their organizations will focus on optimizing and sustaining their current telehealth programs in 2023 rather than expanding them. In fact, only about 10% of participants — 11% of hospitals and 8% of practices — said they are looking to grow their telehealth offerings next year. Health system executives were more likely than practice leaders to say that telehealth visits should make up a higher percentage of their ideal in-person-to-telehealth visit mix. Health system leaders said the mix should be 30% telehealth and 70% office. Among practice leaders, the ideal mix looks more like 20% and 80%. Their difference of opinion also extended to another question on how they think telehealth utilization will grow by visit type over the next two years. Health system leaders said that utilization will fall slightly for most visit types — even behavioral health. They said that 36% of behavioral health visits were delivered via telehealth in September, but they expect this to fall to 33% in September 2024. Urgent care and telepathology were the two visit types for which health systems leaders predicted telehealth growth — they expect telehealth utilization to increase from 3% to 7% for urgent care and from 2% to 4% for telepathology. Practice leaders expected telehealth utilization to increase slightly or remain the same for most visit types. Specialty care was the only exception — for this visit type, practice leaders predicted utilization to fall from 23% to 20% over the next two years. Both groups agreed that telehealth actually increases burden on staff though practice leaders seem to feel it more acutely. More than half of practice leaders said telehealth has increased support staff’s workload, and 28% said it generates more work for nurses. Among health system executives, 35% said telehealth increased support staff’s workload, and 30% said it creates more work for nurses. Additionally, less than half of total respondents (46% of hospitals and 47% of practices) agreed that telehealth increases physician satisfaction and physicians like using telehealth visits to treat patients. A key reason for this is that many providers are operating their telehealth programs using inefficient workflows, according to the report. Nearly 60% of survey respondents said they have not yet created new workflows for telehealth visits. Instead, hospitals and physician practices are still relying on workflows that mirror in-person visits. In 2023, providers will need to improve these workflows, and many will consider bringing on the help of third-party telehealth administrators, such as Amwell or Caregility, the report said. Hospitals are more than twice as likely to use third-party partners to administer telehealth services — with 20% of hospitals doing this compared to 9% of practices. Hospitals were also more likely to say they would change their telehealth administering party over the next two years — with 44% of hospitals saying this compared to 25% of practices. Photo: Anastasia Usenko, Getty Images See original article: https://medcitynews.com/2022/12/report-telehealth-programs-increase-workload-for-nurses-and-support-staff/ < Previous News Next News >

Telemedicine & Telehealth: For Allied Health Professionals, Too Faith Lane April 20, 2022 With more and more people using telehealth applications since the pandemic, one education expert asked how to expand training to include Physical Therapists and Occupational Therapists According to a recent study, one in five adults polled about health care during the coronavirus pandemic said that they or someone in their household delayed receiving medical care or were unable to get care, due to office closures or shutdowns. Although the pollsters focused questions about doctor or dental appointments, providers across the board experienced disruption in their specialty areas, including Peggy Stein, OTD, OTR/L, CHT, an Occupational Therapist in Oregon. Occupational therapy, or OT, focuses on how people perform activities that are most important to their daily lives, so for people who need it, missing out affects quality of life, according to Stein. “OT is important to assess the ability of people to participate in usual activities. Work is important and many people equate occupation with work. However, life involves more than work. Participating in life includes taking care of ourselves, our family and friends, pets, home, yard, or attending to community. These are all ‘occupations’,” Stein said. “The state did halt therapy for a few weeks, and many providers had upheaval for several months,” she said. And while Stein eventually returned to her practice, the buzz surrounding providing telehealth continued in the medical and therapeutic communities. “Back in March 2020, we hosted a webinar. We had numerous occupational therapists, physical therapists (PTs) and speech language pathologists (SLPs) in attendance; more than we have previously seen attending our telemedicine training programs,” said Melanie Esher-Blair, MAdm, Distance Education & Event Coordinator for the Southwest Telehealth Resource Center (SWTRC) and the Arizona Telemedicine Program (ATP). “They wanted more information on how to put the ‘tele’ into their scope of practice to maintain continuity of care for their clients,” said Esher-Blair. She said she knew the SWTRC and the ATP had the experts for developing a program. Both OT and PT national associations have information regarding how telehealth fits into the scope of practice, so attendees of the March webinar agreed creating a training around telehealth was important. An interdisciplinary team worked together to come up with the Occupational and Physical Therapy Webinar Series. For full post and access to video: https://southwesttrc.org/blog/2022/telemedicine-telehealth-allied-health-professionals-too < Previous News Next News >

Legislators Throughout the Southwest are Moving Towards Institutionalizing Telehealth Services Kirin Goff, Southwest Telehealth Resource Center July 2021 Legislatures across the southwest have sprung into action to enact bills that permanently expand telehealth services As the COVID-19 pandemic becomes increasingly under control and more states are ending their public health emergency declarations, legislatures across the southwest have sprung into action to enact bills that permanently expand telehealth services. At the forefront of this new legislation is Arizona’s HB 2454 that Governor Doug Ducey signed into law on March 5, 2021 to provide comprehensive amendments to the state's laws governing telehealth. In Arizona and other southwest states’ new telehealth laws, entities are generally prohibited from denying coverage for telehealth services and are required to cover remotely provided services at the same rate as equivalent in-person services. Exceptions to these requirements may be developed by an advisory committee of government officials, practitioners, and other stakeholders, who will determine, among other things, circumstances in which telehealth services are inappropriate. Even in the absence of a rule prohibiting telehealth services, healthcare providers must use good faith in determining whether telehealth services are appropriate, and if so, which communication modalities are appropriate. Communication Modalities Prior to the public health emergency response to the pandemic, audio-only services were generally permissible only if the healthcare provider had an existing relationship with the patient and audio-visual communication was not reasonably available. Voicemail was specifically excluded. Going forward, telehealth services in Arizona may be provided, when appropriate, through interactive audio/video, asynchronous store-and-forward technology (i.e., digitally stored medical imaging, multimedia files, other information that can be reviewed remotely), and remote patient monitoring technology. Legislation in other states throughout the southwest also includes measures that govern the types of communications by which telehealth services can be provided. In many cases, telehealth can be provided by means other than real-time, audio-visual communication. Nevada SB 5, for example, amends an existing definition of telehealth to include audio-only interactions. Utah's SB 161, which was enacted, allows providers to use HIPAA-compliant asynchronous audiovisual technology for certain treatments. Amendments to New Mexico's Cannabis Regulation Act (HB 2, also enacted) provide a patient to be diagnosed as a qualified patient via telemedicine, which includes store-and-forward and remote patient monitoring technologies as options. Collection and Reporting of Telehealth Data to Form Policy Decisions Legislators in Nevada, like those in Arizona, seek to collect and use data on telehealth services to aid in forming policy. Nevada SB 5 requires the state's Department of Health and Human Services to establish (if funding permits) a data dashboard allowing analysis of access to telehealth by different groups and populations. The bill goes further to include behavioral health boards, the Patient Protection Commission, and the Legislative Committee on Health Care to use the dashboard in formulating policy. Another Nevada bill (ACR 5) establishes a legislative committee to address the shortage of behavioral health professionals in the state. This committee will study the provision of behavioral health services through telehealth and consider ways to expand the use of telehealth to provide such services. Expansion of Services Various bills explicitly expand telehealth services in particular fields such as dentistry (Colorado SB 21-139, New Mexico SB 200), audiology and speech pathology (Colorado SB 21-021, New Mexico HB 210), occupational therapy (Colorado HB 21-1279), and dietetics and nutrition (New Mexico HB 147). Other measures are aimed at expanding broadband access:(Nevada AB 388; Colorado HB 21-1109), including efforts specifically directed at underserved communities (Arizona HB 2885, Nevada AB 388), seniors (Colorado SB 21-210, New Mexico SM 6), and children (New Mexico SM 15). In-Person Medical Examination Requirements In-person requirements have long been a contentious topic in the provision of initial telehealth services in certain contexts. For example, Arizona’s HB 2454 prohibits providers from prescribing Schedule II drugs after an audio-only communication with the patient, but generally allows other drugs to be prescribed after audio-only telehealth communications. In another context, Nevada’s SB 266 provides for in-person medical examinations for workers' compensation claims, but only if initial examinations were performed through telehealth services and only if a party requests an in-person examination. Interestingly, some bills seek to relax restrictions. For example, New Mexico’s HB 12 seeks to eliminate a previous requirement that a practitioner could only certify a patient for medical cannabis use if the practitioner had previously examined the patient in-person. Overall, the surge of bills moves us towards institutionalizing telehealth. Importantly, the latest round of legislation also exposes how much more there is to learn about optimizing telehealth and identifying best practices as uptake continues to increase across the southwest. New Mexico HB 147: https://track.govhawk.com/public/bills/1414538 New Mexico SM 6: https://track.govhawk.com/public/bills/1425880 New Mexico SM 15: https://track.govhawk.com/public/bills/1443803 New Mexico’s HB 12: https://track.govhawk.com/public/bills/1428580 Source: https://southwesttrc.org/blog/2021/legislators-throughout-southwest-are-moving-towards-institutionalizing-telehealth < Previous News Next News >

New Wave of Federal Bipartisan Bills to Expand Telehealth Center for Connected Health Policy June 2021 A good majority of the recently introduced bills focus on increasing telehealth reimbursement, however a few look to increase funding for telehealth services and infrastructure. At present, CCHP is tracking over 100 pieces of telehealth legislation in the current federal legislative session. This month we have seen a number of bipartisan bills introduced, continuing the federal push to expand telehealth availability and codify flexibilities allowed during the COVID-19 public health emergency (PHE). A good majority of the recently introduced bills focus on increasing telehealth reimbursement, however a few look to increase funding for telehealth services and infrastructure. It is notable the significant amount of support from both sides of the aisle for telehealth. For instance, representatives Dan Newhouse (R-WA) and Tom O’Halleran (D-AZ) introduced the Rural Remote Monitoring Patient Act (HR 4008) that would establish a pilot grant program to support the use of remote patient monitoring in rural areas. Senator John Kennedy (R-LA) introduced as part of a package of telehealth bills a reintroduction of a bill similar to legislation from 2020 titled the Telehealth Health Savings Account (HSA) Act (S 2097). The Telehealth HSA Act would allow employers to offer high-deductible health plans that include telehealth services without limiting employees’ ability to use health savings accounts. According to Kennedy’s press release, “a current IRS regulation stops employees from making or receiving contributions to HSAs if they hold a high-deductible health plan that waives the deductible for telehealth services, meaning employees holding high-deductible health plans often need to pay out of pocket for telehealth services. The Coronavirus Aid, Relief and Economic Security (CARES) Act (HR 748) temporarily waived this regulation, but S 2110 would make the waiver permanent.” We have also seen a few of the recent bills look at audio-only and codifying pandemic telehealth flexibilities. The Protecting Rural Telehealth Access Act (S 1988) by Senator Joni Ernst (R-Iowa) and also sponsored by Senators Jerry Moran (R-Kan.), Joe Manchin (D-W.Va.), and Jeanne Shaheen (D-N.H.), would: *Allow payment parity for audio-only telehealth services *Make permanent the ability for patients to be treated at home *Let rural health clinics (RHCs) and federally qualified health centers (FQHCs) serve as distant sites for telehealth services The Advancing Telehealth Beyond COVID-19 Act of 2021 by Representative Liz Cheney (R-Wyo.), introduced with Representative Debbie Dingell (D-MI), makes the following permanent changes: *Removes originating site and geographical limitations *Maintains telehealth flexibilities for RHCs/FQHCs *Expands coverage for audio-only services *Removes restrictions that limit clinicians’ ability to remotely monitor and track patient health and provide them access to innovative digital devices Additionally, we have seen bipartisan support around broadband legislation, such as from Senators Michael Bennet (D-Colo.), Angus King (I-Maine), and Rob Portman (R-Ohio), who recently introduced legislation which seeks to address the digital divide. Their Broadband Reform and Investment to Drive Growth in the Economy (BRIDGE) Act of 2021 would allow states to deploy “future-proof” networks able to meet communities’ broadband needs, including supporting local initiatives on affordability, adoption, and inclusion. According to Bennet’s press release, The BRIDGE Act would: *Provide $40 billion to States, Tribal Governments, and U.S. Territories for affordable, high- speed broadband *Prioritize unserved, underserved, and high-cost areas with investments in “future proof” networks *Encourage gigabit-level internet wherever possible while raising the minimum speeds for new broadband networks to at least 100/100 Mbps, with flexibility for areas where this is technologically or financially impracticable *Emphasize affordability and inclusion by requiring at least one affordable option *Increase choice and competition by empowering local and state decision-making, lifting bans against municipal broadband networks, and allowing more entities to compete for funding Lastly, additional information was just released regarding Cures 2.0 – another bipartisan bill, which creates the Advanced Research Projects Agency for Health (ARPA-H), a President Biden budget request proposal. According to a discussion draft and section-by-section summary, Cures 2.0 will address a variety of areas, including telehealth access, while incorporating and building upon several additional bipartisan bills, such as the Telehealth Improvement for Kids’ Essential Services (TIKES) Act (H.R. 1397 / S. 1798) and Telehealth Modernization Act (H.R. 1332 / S. 368). The telehealth provisions proposed in Cures 2.0 include: *Review the impact of telehealth on patient health and encourage better collaboration *Provide guidance and strategies to states on effectively integrating telehealth into their Medicaid program and Children’s Health Insurance Program (CHIP) *Make many of the COVID-19 PHE flexibilities post-pandemic permanent, such as: -Removing the geographic and originating site restrictions -Expanding the range of health care providers that can be reimbursed by Medicare for furnishing telehealth services to any health care professional eligible to bill Medicare -Enhancing telehealth services for use by FQHCs, RHCs, hospices, and for home dialysis The authors anticipate that the Cures 2.0 bill will be introduced in the coming weeks and hope to see it signed in the fall. While the fate of these telehealth bills is yet to be seen, it does seem to highlight strong federal support for expanding access to telehealth post PHE with such a large amount of bipartisanship support behind them. Given Medicare’s historically conservative approach in regard to telehealth pre-PHE, any additional shift would be significant. CCHP will continue to update its tracking tools and monitor the ever evolving telehealth landscape as we continue to move through the current federal legislative session. < Previous News Next News >

CCHP Leadership Provides A Look Back at Telehealth Policy in 2022: Yes...The Year is Almost Over! Mei Kwong December 20, 2022 As another full year of living under the public health emergency (PHE) for COVID-19 comes to an end, we are taking a look back to see what has happened this year with telehealth policy on both the federal and state level. Since the PHE is still in place and likely to continue into 2023, permanent changes on the federal level have been fewer in comparison to what many states have been doing. In fact, some states began making permanent telehealth policy changes as early as late 2020. Other states have taken similar actions to their federal counterparts and put a definitive future expiration date on temporary telehealth policies. FEDERAL The most significant federal legislative telehealth policy action seen this year took place in the Budget Act of 2022 which included language extending some of the temporary waivers to telehealth in Medicare for an additional 151 days after the PHE. This statutory change led to additional clarifications that the Centers for Medicare and Medicaid Services (CMS) made in their Physician Fee Schedule for 2023 (PFS). CCHP also recently released a fact sheet on the relevant telehealth policies. The final result as the policy stands now is: For 151 Days After the PHE: Certain providers including federally qualified health centers (FQHCs), Rural Health Clinics (RHCs), occupational therapists, and physical therapists may continue to provide eligible services via telehealth under the Medicare program. The list of temporary services eligible to be delivered via telehealth and covered by the Medicare program will continue to be available during this 151-day period. The geographic limitations under permanent telehealth Medicare policy will be suspended during this 151-day period and the home will continue to be an eligible originating site for all eligible services during the extension. Audio-only can continue to be used as a modality for eligible services during the 151-day extension. Permanent policy requirements such as a previous in-person visit for mental health services taking place in a non-geographically eligible location, in the home or via audio-only is suspended during this 151-day period. Certain other federal waivers that exist under the PHE are currently not included in this 151-day grace period. This includes the Office of Civil Rights (OCR) exercising discretion in enforcing HIPAA which OCR has noted will expire when the PHE is declared over or expires, whichever comes first. As can be seen by the foregoing, very little has changed this year regarding permanent policy, just what will happen in the immediate aftermath of the end of the PHE. There have been some indications that Congress may pass legislation to extend the federal waivers, or at least some of them, beyond the 151-day period. HR 4040 authored by Representative Liz Cheney (R, WY) passed the House earlier this year, but no further action was taken. That bill would have extended some of the temporary waivers for an additional two years. However, what might be considered by Congress now is rumored to be only a one-year extension. It remains to be seen if some additional action will be taken legislatively. Feeding into the federal policymakers’ decision-making process have been several reports from various federal agencies in the past year. The Office of the Inspector General (OIG) released several reports around telehealth in 2022 including: Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others to Use Telehealth During the First Year of the COVID-19 Pandemic Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks The last study listed above is important to take note of given the concerns raised by policymakers for the potential of abuse and fraud. However, the OIG report noted that in the first year of COVID-19, less than 1% of telehealth claims made to Medicare raised flags for potential fraud, which should provide some reassurance to policymakers. Broadband has been an issue both on federal and state policymakers’ minds. While connectivity is a greater issue beyond how it impacts telehealth, it cannot be denied that telehealth will simply not work if the patient and provider cannot connect, although policy expansions related to audio-only have sought to mitigate this gap to a certain extent. In 2022, the Federal Communications Commission transitioned the Emergency Broadband Benefit Program into the Affordable Connectivity Program which provides assistance in paying for connectivity. The National Telecommunications and Information Administration (NTIA) compiled federal funding opportunities that support broadband planning, digital inclusion and deployment projects on one site. States have also been gearing up activity around broadband, some of it funded by the federal government such as NTIA awards to Nebraska to develop strategic plans to expand high-speed broadband and other investments made by the state itself. No doubt, broadband will continue to be a significant issue in 2023. STATES As CCHP’s recent Legislative Roundup newsletter noted, 2022 was another active year for state telehealth policy legislation, though not as robust as it was in 2021. Overall, in 2022, of the bills enacted and subjects CCHP tracked, licensure proved to be the most popular policy issue addressed with 61 bills across the states passing. This was followed by 27 enacted bills related to professional regulations and telehealth, many having to do with prescribing and 18 bills for pilot/studies/demonstrations. Enacted Medicaid and private payer reimbursement bills were 17 and 12, respectively. The licensure focus is of particular interest to note. While many of the pieces of legislation passed related to joining licensure compacts, states also made exceptions to licensure for specific situations. States are starting to address the various situations usually involving an already established relationship between patients and providers that prior to the pandemic had remained grey areas. A common concern raised during the pandemic related to licensure involved a patient temporarily re-locating to another state, perhaps as a college student, going on vacation or caring for a family member, but still wanting to receive services from their own provider in their home state. Kentucky passed HB 188 that forbids a regulatory board from promulgating regulations related to telehealth that prohibit “the delivery of telehealth services to a person who is not a permanent resident of Kentucky who is temporarily located in Kentucky by a provider who is credentialed by a professional licensure board in the person’s state of permanent residence.” While clarity is always welcomed, the exceptions individual states are passing will create more complexity in the telehealth policy landscape particularly for practitioners who provide services in multiple jurisdictions. Reimbursement is an area that generates significant interest. For Medicaid related legislation, the type of modality used and services that would be covered under the program were popular issues addressed through legislation. For example, Virginia SB 426 requires the Medicaid state plan be amended to allow for remote patient monitoring (RPM) services for patients with certain types of medical conditions such as high-risk pregnancy and transplant patients when there is evidence that use of RPM is likely to prevent readmission to a hospital. Private payer telehealth legislation can also be quite specific. Louisiana HB 304 now requires telehealth coverage and payment parity equivalent to in-person services for physical therapy in particular. However, what we also saw were legislators moving towards ensuring there were patient protections/choice codified in state laws related to private payer plans and telehealth. Mississippi SB 2738, among other things, states that insurers cannot limit coverage of services to select third-party organizations. Commercial plans only offering telehealth delivered services to enrollees through a third party and not allowing their in-network providers to use telehealth has been a concern that was growing even prior to the pandemic. This stems from concerns raised by policymakers regarding patient choice or patients being “forced” to use telehealth and continuity of care concerns that continue to exist today. Overall, the number of states expanding telehealth policies increased. As noted in CCHP’s latest update to its 50 State Telehealth Policy Summary Report, Fall 2022, compared to its Fall 2021 update, three more state Medicaid programs are covering store-and-forward telehealth, five more states are covering RPM under Medicaid, and state Medicaid programs covering audio-only went up from 22 states to 34 states and DC. Additionally, three states have added payment parity requirements to their private payer laws. WHAT’S NEXT FOR 2023? As noted above, rumors have swirled around that there may be movement on the federal level to extend some of the telehealth waivers beyond the 151-day grace period, similar to what was proposed in the Cheney bill. However, it is likely that any such change will be included in a larger bill, such as the budget bill, rather than a standalone telehealth bill. There are also several outstanding issues that continue to not be addressed such as the registry for telehealth that the Drug Enforcement Administration (DEA) was to finalize regulations for in 2019. Some may recall that among the list of exceptions to allowing telehealth to be used to prescribe a controlled substance without the telehealth provider having examined the patient in-person included when a PHE was declared and the creation of a registry. For the registry, presumably once a provider is qualified to be on the registry, they need not have to meet any of the other narrow exceptions to prescribe via telehealth. That registry has never been created, though Congress had directed the DEA to finalize regulations by the end of 2019. On the state level, we likely can expect to see continued action around coverage, licensure, and professional regulations, as well as continued discussion around patient choice. During this past year, there has been increased discussions regarding “telehealth-first” health plans and the impact on patient choice. Whether policymakers take a more active role in regulating these plans remains to be seen, but the discussion around patient choice protections will continue. One thing is clear: the telehealth policy landscape is by no means “settled” as 2022 draws to a close. Outstanding questions around temporary policies still remain and even settled policies implemented a year or so ago have been tweaked in some states. To hear more about what's occurred in 2022, plus what we can anticipate for 2023, watch CCHP's newest short video. As we head into 2023 we can be certain that the telehealth policy landscape will continue to evolve and change, and we look forward to having you continue on this journey alongside CCHP. Have a Happy New Year and see everyone in 2023! Mei Kwong, CCHP Executive Director See original article: https://mailchi.mp/cchpca/cchp-leadership-provides-a-look-back-at-telehealth-policy-in-2022-yesthe-year-is-almost-over < Previous News Next News >

Telehealth Waivers Wind Down, Restricting Some Providers From Delivering Care Across State Lines Hailey Mensik August 2021 States allowed medical professionals licensed elsewhere to hold virtual visits with their residents during the pandemic. Some are making the rollbacks permanent, but others are reversing again. State lawmakers temporarily scrapped hundreds of regulations early in the COVID-19 pandemic to help businesses and consumers deal with widespread shutdowns, giving patients greater access to telehealth and helping spur an explosion in use of virtual care. A number of states allowed medical professionals licensed elsewhere to hold telehealth visits with residents of their state during the pandemic, and some already have or are looking to make the rollbacks permanent. Exact numbers are difficult to track because some policies overlap and are organized differently in different states, but as of July 28, 17 states and the District of Columbia still had some type of telehealth waivers in place, according to the Federation of State Medical Boards. Other states like New York, Minnesota, Florida and Alaska are among those that have pulled back emergency waivers. Alaska is going back to its old ways after its governor's emergency order ended. Patients there can only visit telehealth providers licensed in the state now after about a year without that rule. The same goes for Florida after its emergency declaration expired on June 26. Meanwhile, Arizona lawmakers passed sweeping legislation in May making the state's pandemic-related telehealth waivers permanent, including requiring insurers to cover audio-only visits and allowing out-of-state medical professionals to conduct telehealth visits with patients in the state. Advocates for allowing providers to permanently deliver virtual care across state lines say it would help ease staffing shortages, help patients and doctors maintain existing relationships and benefit patients in isolated communities by making faraway specialists more accessible. But as long as medical licensing is regulated at the state level, the broad access to services and providers that existed during the pandemic won’t continue for everyone. Patients in rural areas are often far away from a doctor's office, and in states like Alaska where flexibilities expired, can be even further from providers practicing certain specialties, such as a pediatric intensivist or certain oncologists, said Mei Kwong, executive director for the Center for Connected Health Policy. "Maybe there aren't enough of those cases in those particular states to make it worth a provider's while to go and move there, but there's still a need because they may still have people who need those services," Kwong said. The patchwork of red tape could also pose a challenge for providers who have pivoted to delivering more virtual care over the past year. Mia Finkelston, a family medicine physician in Maryland, made the switch to telehealth nearly a decade ago and has been practicing with Amwell ever since. She's currently licensed in 29 states, and said the process to get her licenses varied widely. "It's not standard as far as fees, it's not standard as far as what documents you need to give them. It really is based on those state medical boards and what they decide is important to them," Finkelston said. As more states' waivers expire and others' rules change, one option for providers who want to continue delivering care across state lines is through the Interstate Medical Licensure Compact, which currently includes 30 states, the District of Columbia and Guam. Similar to the nurse licensure compact, it allows eligible physicians to practice in other compact states. It’s worth noting, however, that the Interstate Medical Licensure Compact does not issue a compact license or a nationally recognized medical license for physicians, but rather streamlines the process for them to receive multiple licenses from individual state medical boards. Physicians pay an initial $700 compact fee, then an additional cost for each license in any compact state they want to practice in. States must pass legislation to join the compacts. "No two states are totally alike in their legal and regulatory framework for the practice of medicine, which of course, affects telehealth, which is just one aspect of the overall US healthcare system," Kyle Zebley, director of public policy at the American Telehealth Association, a coalition with a board that includes representatives from hospitals like HCA and payers like CVS, said. "Therefore a way to be consistent with our federal system, consistent with the way that the practice of medicine has been done in this country for so long, we've come up with this great model of compact, which is a way to be consistent with all that while still allowing for care across state lines," Zebley said. As lawmakers try to facilitate continued access to telemedicine for those who need it most, licensure reforms will be key, the authors of a February article in the New England Journal of Medicine argue. "The growth of large national and regional health systems and the increased use of telemedicine have expanded the scope of health care markets beyond state borders," the authors said. They agree that a federal medical licensing system is the loftiest reform option and strengthening existing compacts is the way to go, suggesting Congress pass legislation to encourage holdout states to join the Interstate Medical Compact. Other options include encouraging states to practice reciprocity, where they automatically recognize an out-of-state license, as the Department of Veterans Affairs does with physicians in its system. Source: https://www.healthcaredive.com/news/telehealth-waivers-wind-down-restricting-some-providers-from-delivering-ca/603169/#:~:text=Healthcare%20Dive-,Telehealth%20waivers%20wind%20down%2C%20restricting%20some%20providers%20from%20delivering%20care,but%20others%20are%20reversing%20again. < Previous News Next News >

Grants & Funding The Federal government has numerous funding sources for telehelath support: USDA Community Connect Grants USDA Distance Learning and Telemedicine Grants Other Telemedicine Grants FCC Rural Health Care - Healthcare Connect Fund USDA COMMUNITY CONNECT GRANTS ​ This federal program funds broadband deployment into rural communities where it is not yet economically viable for private sector provi ders to deliver service. For more information, please visit USDA Community Connect Grants . ​ ​ USDA DISTANCE LEARNING AND TELEMEDICINE GRA NTS ​ Th is federal program helps rural communities use telecommunications' unique connectivity capabilities to overcome effects of remoteness and low population density. Grant funds may be used for a cquisition of eligible capital assets, such as: Technical assistance and instruction for using eligible equipment ​ Inside wiring and similar infrastructu re that further DLT services Acquisition of instructional programming as a capital asset Computer hardware, network components, and software Audio, video, and interactive vid eo equipment Terminal and data terminal equipment For more information , please visit USDA Distance Learning and Telemedicine Grants . ​ ​ OTHER TELEMEDICINE GRANT OPPORTUNITES ​ The Health and Human Services Division for telehealth and broadband related programs posts funding opp ortunities HE RE . ​ ​ HEALTHCARE CONNECT FUND ​ The New Mexico Telehealth Alliance (N MTHA) manages the Southwest Telehealth Access Grid (SWTAG), a Federal Communications Commission (FCC) approved consortium for funding through the Healthcare Connect Fund (HCF). If you manage one or more healthcare provider sites serving clients in New Mexico, contact NMTHA to discuss joining SWTAG. Advantages to applying to SWTAG via NMTHA include: Lower application and administrative costs. Access to expert funding advice for a mix of rural and urban sites. Professional assistance with proven track record of funding success. Additional information on eligibility and application procedures can be found HERE . ​ Community Connect Distance Learning Other Healthcare Connect

CONGRESS UNVEILS TWO YEAR EXTENSION OF TELEHEALTH FLEXIBILITIES – AS URGED BY THE ATA AND ATA ACTION – AS PART OF OMNIBUS BILL The American Telemedicine Association December 20, 2022 Today, the American Telemedicine Association (ATA) and ATA Action express their gratitude to the U.S. Congress for unveiling a bipartisan, bicameral omnibus appropriations bill that includes a two-year extension for Medicare telehealth provisions put in place during the COVID-19 public health emergency (PHE). The omnibus package also includes a two-year delay in implementing the Medicare telemental health in-person requirement, a two-year extension of the safe harbor to offer telehealth in High Deductible Health Plans (HDHPs) with Health Savings Account (HSAs), and a two-year extension of the Acute Hospital Care at Home Program. Congress is expected to vote on the omnibus bill and send it to President Biden to be signed into law within the next week. The omnibus did not include a comparable extension past the end of the PHE of the Ryan Haight in-person waiver for the remote prescription of controlled substances. However, the legislation does include language directing the Drug Enforcement Administration (DEA) to promulgate final regulations specifying the circumstances in which a Special Registration for telemedicine may be issued and the procedure for obtaining the registration. “The ATA and ATA Action never wavered from our appeal to Congress, to provide stability around the life-saving telehealth flexibilities that have become a relied upon and valued option for healthcare providers and patients. Today, our Congressional telehealth champions on both sides of the aisle came through for the American people and for ATA and ATA Action members, by meeting our plea for more certainty around telehealth access for the next two years, while we continue to work with policymakers to make telehealth access a permanent part of our healthcare delivery for the future,” said Kyle Zebley, senior vice president, public policy, American Telemedicine Association, and executive director, ATA Action. “We asked Congress and they listened. We are truly grateful for their staunch support of telehealth. It’s now time to swiftly bring this bill to the President, for passage into law before year-end.” Stakeholder Letter to Congressional Leadership – Urging Extension of Telehealth Flexibilities Stakeholder Letter Urging Congress to Act on the Telehealth High Deductible Health Plan Safe Harbor Tax Provision ATA’s Recommendation’s for Acute Hospital Care at Home Program Stakeholder Letter Urging the DEA to Act on the Prescription of Controlled Substances via Telehealth Before the PHE Expires “We greatly appreciate Congress including extensions the High Deductible Health Plan (HDHP) and Health Savings Account (HSA) telehealth tax provision, giving American workers continued access to needed telehealth coverage without first having to meet annual deductibles, including telemental health services. Further, the extension to the Acute Hospital Care at Home Program ensures continued access to this patient-centered care delivery model that is proving to effectively lower cost of care while improving patient health outcomes and satisfaction. “The ATA and ATA Action are delivering on our promise, to advocate for permanent access for telehealth services and today marks a significant milestone towards that goal. But the hard work continues, as we persist in pressing telehealth permanency and creating a lasting roadblock to the ‘telehealth cliff.’ Additionally, we will continue to work with Congress and the Biden administration to make sure that a predictable and preventable public health crisis never occurs by giving needed certainty to the huge number of Americans relying on the clinically appropriate care achieved through the Ryan Haight in-person waiver.” About ATA Action ATA Action recognizes that telehealth and virtual care have the potential to transform the healthcare delivery system by improving patient outcomes, enhancing the safety and effectiveness of care, addressing health disparities, and reducing costs. ATA Action is a registered 501c6 company and an affiliated trade organization of the ATA. About the ATA As the only organization completely focused on advancing telehealth, theAmerican Telemedicine Association is committed to ensuring that everyone has access to safe, affordable, and appropriate care when and where they need it, enabling the system to do more good for more people. The ATA represents a broad and inclusive member network of leading healthcare delivery systems, academic institutions, technology solution providers and payers, as well as partner organizations and alliances, working to advance industry adoption of telehealth, promote responsible policy, advocate for government and market normalization, and provide education and resources to help integrate virtual care into emerging value-based delivery models. See original article: https://www.americantelemed.org/press-releases/congress-unveils-two-year-extension-of-telehealth-flexibilities-as-urged-by-the-ata-and-ata-action-as-part-of-omnibus-bill/ < Previous News Next News >

My Story: A Patient’s Perspective Tara Barry January 27, 2022 The pandemic has created a lot of new realities throughout the world, telemedicine being one of them. As someone with thyroid disease and other ailments, I have to get regular check-ups (sometimes every month when it’s really flaring up). With my health issues, I see multiple different doctors (primary, cardiologist, endocrinologist, allergist), and it’s often very hard for me to find time to fit them all in to my already jam-packed schedule. Telemedicine has been such a welcome adaption for me, as it has truly taken a lot of the usual “appointment” stress, like commute time, completely out of the equation. During the pandemic, I’ve been particularly cautious about in-person appointments. Since I am someone with a weakened immune system, it makes me nervous going into such a historically germ-filled location such as a doctors’ office. Telemedicine appointments truly put me at ease. I have had experience with ‘televisits’ for both primary care and specialty care. I’ve been able to have a quick appointment on my lunch break and sometimes even during a short 15-minute break. When I made my first appointment I was a little nervous about how it would be. I didn’t know if I’d feel more rushed and like they were just squeezing me into their busy day or not. It was a relief to find that wasn’t the case at all. I find these appointments to actually be much more conversational than in-person visits, and also feel like they really get down to the issues faster. You can learn about treatment options in mere minutes and have your prescriptions sent in while you’re still on the call! I am someone who is technologically savvy so I wasn’t too worried about being able to successfully hop on to a telemedicine call. I think the various systems different doctor’s offices use make all the difference. In my experience, I have always been given the telehealth links ahead of time and the instructions have been very clear and concise. Typically, the medical assistant will call prior to the appointment to go over your medical history, insurance information, what your appointment will be focused on, and the instructions to get on the call. Sure, there’s been a few times we’ve had some connection issues, but they always seem to resolve themselves quickly and don’t take away from the appointment itself. To read full article: https://telemedicine.arizona.edu/blog/my-story-patient-s-perspective < Previous News Next News >

Controversy about Eliminating Telephone Telehealth Coverage By Dr. Maheu April 7, 2021 Clinicians do not typically know how much they don’t know about using the technology until they start a serious course of telehealth training. Only then do they realize how many basic assumptions are incorrect and many of the strategies that they learned in school now need to be re-considered to meet legal and ethical standards. A study published in the Journal of the American Medical Association focused on telehealth use among the low-income population in California. The study included data from outpatient primary care and behavioral health visits from February 2019 to August 2020 at forty-one federally qualified health centers representing 534 locations in California. The study showed that, with regards to primary care visits, 48.5% of visits occurred via telephone, 48.3% occurred in person, and 3.4% occurred via video. For behavioral health visits, 63.3% via telephone, 22.8% in person, and 13.9% via video. The study’s key finding was that most telehealth appointments during the pandemic period were conducted over the phone. “Eliminating telehealth coverage for audio-only telemedicine visits would disproportionately impact underserved communities,” according to Lori Uscher-Pines, the study’s lead author. “Lower-income patients may face unique barriers to accessing video visits, while federally qualified health centers may lack resources to develop the necessary infrastructure to conduct video telehealth,” she said. “These are important considerations for policymakers if telehealth continues to be widely embraced in the future.” Since the use of telehealth expanded due to COVID, few studies have examined differences in the use of telehealth modalities. However, one federal agency estimated that 30% of telehealth visits had involved phone therapy sessions alone during the pandemic. According to the study, telehealth visits delivered via over-the-phone therapy peaked in April 2020, comprising 65.4% of primary care visits and 71.6% of behavioral health visits. Before the pandemic, many definitions of telehealth excluded phone therapy visits, and private insurers or the government rarely reimbursed them, the study authors noted. Some payers, including the Centers for Medicare and Medicaid Services, have indicated they may stop telehealth coverage reimbursement for phone therapy sessions when the pandemic ends. Read more about previous rulings for COVID-19 Telephone Telehealth Reimbursement. “There are some concerns that telephone visits could result in fraud, abuse, and unnecessary and lower-quality care. Although these concerns are important to assess, eliminating telehealth coverage for telephone visits could disproportionately affect underserved populations and threaten the ability of the clinics to meet patient needs” stated Dr. Uscher-Pines. The Reality of Professionalism and Telephone Therapy It seems a bit dramatic to point out that telephone therapy can be more subject to fraud and abuse when it actually is often the only lifeline for many people in distress during the pandemic, and beyond. Fraud and abuse can potentially exist everywhere. The real question is whether the professional has bothered to learn how to properly use the telephone for clinical interventions – or if they are making it up on the fly. Unfortunately, although a clear evidence base exists for telephone-based interventions, very few professionals have received adequate training, and more likely, no professional training to use only the telephone to deliver services to a patient or client. They may not have yet realized that a good in-person clinician is not the same as a good telephone therapist, regardless of intention or need. This point can be clarified quite readily by looking at the case of the alcoholic therapist-in-recovery who now decides to offer therapy for alcohol use. Assuming of course that the therapist has excellent therapy skills to start, the therapist’s history with alcohol can actually interfere with their functioning as an addictions therapist, narrowing perspective with unchallenged assumptions related to etiology, treatment options, and/or prognosis. This is why the professional standard for qualifying alcohol therapists is not one’s prior experience with alcohol, but rather, a course completion certificate or certification in alcohol interventions. Even a good (or great) in-person therapist approaching telephone telehealth without training is likely to overestimate the quality and/or effectiveness of their communications. If one does read the literature about telehealth in general and telephone therapy in particular, it is very clear that professional training in order. In fact, most published studies directly call for clinicians to get such training for telehealth and telephone therapy as well. The Telephone Telehealth Evidence-Base The research in telehealth, in general, has also been quite clear that therapists who have received training are more likely to use the medium correctly to deliver outcomes that are not only comparable to in-person care but also to minimize frustration in both themselves and their clients/patients and feel more confident about how to protect the privacy of the exchange. In 2018, after conducting a systematic search for articles published over a 25-year period (January 1991–May 2016), Coughtrey & Pistrang published a study of 14 studies that concluded that “telephone-delivered interventions show promise in reducing symptoms of depression and anxiety.” This conclusion is warranted, given that much of the Similarly, in 2020, Castro and colleagues published a meta-analysis looking at 10 studies looking at treatment adherence to telephone therapy for depression. In general, they showed beneficial effects on depression severity when compared to control conditions. However, in these and other published reports showing the effectiveness or adherence rates related to telephone telehealth, treatment models are typically highly manualized. That is, they do not consist of free-form, open discussion common to many psychotherapeutic approaches. Therapists in such studies tend to follow very strict procedural dictates, and often, the recipient of care is given written materials and assignments that coincide with specified topics for each meeting. Conducting a mid-pandemic online qualitative survey of mental health care professionals in Netherlands, Feijt and colleagues (2020) reported, “Regarding the mediated nature of communication, the most frequently reported challenge concerns the lack of nonverbal signals that practitioners normally use in face-to-face communication, such as posture and hand movements, but also general demeanor, including smell. Practitioners find it more difficult to connect with their client or clearly communicate their intended message. This is even stronger when sessions are conducted by telephone when there is only audio to rely on.” Such a conclusion seems warranted, given that in-person training often teaches practitioners to rely on visual stimuli to render a diagnosis, develop and deliver a treatment plan. In evidence-based telehealth professional training, and especially in competency-based certificate programs of professional training, many of these issues can be addressed using protocols that are tailored to the clinician’s specific client for one’s patient population, setting, state, and professional requirements. On the other hand, clinicians who use communication technology without professional training are likely to be as confused by the online delivery of healthcare as someone accustomed to using a handset telephone who now is handed a smartphone to make a simple call. Therapist Vulnerability in Telephone Telehealth? Assessing a client or patient’s emotional state from voice alone can be problematic, particularly if the professional’s prior telephone habits involve multitasking. As discuss by Hilty, Randhawa, Maheu, McKean, Pantera & Mishkin (2020), distractions are the #1 problem with digital interventions. Don’t we all multitask when on the phone? Where then does distractibility leave the busy professional who typically multi-tasks during telephone therapy? Professionals who allow their workspace to be impinged by devices that regularly emit incoming messages, beeps, flashing lights, and other forms of alerts will likely find it difficult to stay focused on the voice input they now are attempting to use to deliver the same standard of care as in-person. Some therapists even so boldly encourage their clients and patients to “take a walk” while they themselves stroll about their neighborhoods or other local public areas while offering telephone therapy. All the while, these professionals profess to be delivering the same standard of care as when the client is seated in front of them, in a closed room. Could these realities be used to discredit an earnest professional who is attempting to deliver quality care via telephone therapy to people in need? Telehealth Service Delivery is Not Intuitive Telehealth service delivery is not intuitive, regardless of one’s experience in person or the need of the client. Faulty assumptions, lack of knowledge, undeveloped skillsets, and naive attitudes can lead to preventable error and potential harm. Pierce, Perrin, & McDonald (2020) stated, “Organizations interested in encouraging telepsychology use should adopt policies supporting the use of telepsychology and provide adequate training to do so.” Such calls for training are common to published reports and mimic those of telehealth in general for more than two decades. In 2000, Maheu and Gordon reported the results of an extensive survey assessing psychologist’s assumptions regarding the legal and ethical requirements for telehealth. Fourteen years later, a similar article was published by Maheu and a larger team of researchers who assessed roughly the same variables. In the 2020 study, two-thirds of clinicians endorsed items suggesting that standard legal and ethical mandates don’t apply to telehealth delivery of psychotherapy (Maheu & Gordon, 2000). In a more extensive survey, Glueckauf, Maheu, Drude, Wells, Wang, Gustafson & Nelson (2018) showed that the number had decreased to one-third. The disturbing fact is, however, that while two-thirds of clinicians endorsed items suggesting an awareness of legal and ethical mandates, it cannot be assumed that those clinicians understood how those mandates apply to their everyday telehealth practices. Where does this leave the average clinician who has no or minimal telehealth training, yet is confident that they are delivering quality care because they “feel good about it” and because it is “needed?” Therapists too are vulnerable to emotional reasoning… Courtroom Realities of Telephone Therapy Knowing how litigating attorneys work, it is quite conceivable that opposing counsel in a lawsuit against a therapist would wield several such recently published telehealth articles in the direction of an unwitting therapist who blithely offers telephone therapy without the proper documentation to prove that they indeed were actually trained in evidence-based telephone telehealth. Perhaps the CIVID emergency would tempter such accusations, depending on the circumstance. Hopefully so. However, the worrisome issue at hand is that most clinicians have never been taught the reality of what actually happens in courtrooms. Such training can be a difficult awakening. To help our readers better understand the issues involved with delivering clinical care in an area where there is a lack of professional training, we will make you privy to a training video that we regularly show in our 2-day certificate training programs. It features Attorney Joe McMenamin demonstrating his litigation skills as a prosecuting attorney for the defense in a “mock deposition.” In this video, he demonstrates exactly how a prosecuting attorney would “prepare” their case against a witness’s testimony for a trial wherein the therapist is being sued by an angry client. The video is painful to watch. Our only solace at TBHI is that Mr. McMenamin has not only worked for decades as a prosecuting attorney for the defense, but he is also a physician. he understands and shares the ethos of many healthcare professionals, and has worked these many years to defend us in court. That’s his motivation for working with TBHI for decades to develop training materials and peer-reviewed books and articles – to help professionals who are poorly informed of what can happen when one is led by the unbridled desire to help rather than a firm grounding in telehealth theory and practice. Caveat While this type of cross-examination wouldn’t happen to professionals who deliver telephone therapy during the pandemic because we are currently in a state of national emergency, but if telephone therapy were to be approved long-term, this is precisely the type of rigor that would be expected of professionals delivering professional services to people in need. As all licensed professionals know, there is a high bar for the delivery of professional services. Practicing licensed healthcare professional in the United States or Canada as well as in many other countries isn’t something one does in the same manner as they would if they were talking to a family member on the phone, multitasking, opening email, glancing at texts, perhaps outside strolling about the park — while the other party probably is also multi-tasking and/or strolling about as well. When we share the video below, please use this information to extrapolate how a skilled professional needs to be able to defend the amount of training they have obtained in any new area of practice including phone therapy sessions alone when a litigating attorney has them on the witness stand. Please note, we at TBHI are not saying this process is fair or right. It simply is reality. Courtroom Realities of Telehealth Malpractice Before watching, please let us explain what is happening in the video. First, this is one of the many training videos that we typically share with our training audiences. You will see how the attorney discredits the psychologist who is named “Dr. Joanne Johnson,” acted by Dr. Marlene Maheu for purposes of this role-play. The cross-examining attorney is Mr. Joe McMenamin, who is indeed a litigating attorney and physician in real life. He, however, defends practitioners in court rather than a prosecuting attorney, which he depicts in this audio lesson. However, having litigated against attorneys who prosecute, he is in a unique position to show you exactly what happens in court, should you ever have the misfortune of experiencing it firsthand. The interactions portrayed in the audio recording are abbreviated because Dr. Johnson provided additional information rather than doing as witnesses are instructed, and that is to give yes/no answers when possible, and offer as little as possible unless directly asked. You will see that Dr. Johnson actually offers a fair amount of information to get to the point of the demonstration. Upon experiencing the agony of witnessing such an exhaustive exchange, but in real life, it would behoove you to obtain the advice of a defense attorney about offering as much information as is depicted. The purpose of the demonstration, in this case, was to show you what a skilled litigator can do to disarm a well-intentioned professional during a deposition. The attorney goes on to explain his rationales, strategies, and how opposing counsel (which he is role-playing) would generally use the information gathered to discredit the plaintiff in court. This first training video is 37 minutes in length. TBHI Position on Telephone Therapy Just to be clear, TBHI is in complete support of phone therapy sessions alone for all clients and patients who need or are interested in such healthcare. However, having been the Chair of the CTiBS Committee on Telebehavioral Health Competencies, the Founder of TBHI is acutely aware of the lack of competence in psychotherapists who deliver such care. Clinicians do not typically know how much they don’t know about using the technology until they start a serious course of telehealth training. Only then do they realize how many basic assumptions are incorrect and many of the strategies that they learned in school now need to be re-considered to meet legal and ethical standards. All untrained professionals then are encouraged to consider serious telehealth training if they wish to be competence and legally and ethically compliant with the evidence base. References Castro, A., Gili, M., Ricci-Cabello, I., Roca, M., Gilbody, S., Perez-Ara, M.A., Seguí, A. & McMillan, D. (2020) Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 260, 514-526, ISSN 0165-0327,https://doi.org/10.1016/j.jad.2019.09.023. Coughtrey, A. E., & Pistrang, N. (2018). The effectiveness of telephone-delivered psychological therapies for depression and anxiety: a systematic review. Journal of telemedicine and telecare, 24(2), 65-74. Feijt, M., de Kort, Y., Bongers, I., Bierbooms, J., Westerink, J., & IJsselsteijn, W. (2020). Mental health care goes online: Practitioners’ experiences of providing mental health care during the COVID-19 pandemic. Cyberpsychology, Behavior, and Social Networking, 23(12), 860-864. Glueckauf, R. L., Maheu, M. M., Drude, K. P., Wells, B. A., Wang, Y., Gustafson, D. J., & Nelson, E. L. (2018). Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, 49(3), 205. Hilty, D. M., Randhawa, K., Maheu, M. M., McKean, A. J., Pantera, R., & Mishkind, M. C. (2020). A Review of Telepresence, Virtual Reality, and Augmented Reality Applied to Clinical Care. Journal of Technology in Behavioral Science, 1-28. https://doi.org/10.1007/s41347-020-00126-x Maheu, M. M., & Gordon, B. L. (2000). Counseling and therapy on the Internet. Professional Psychology: Research and Practice, 31(5), 484. Pierce, B. S., Perrin, P. B., & McDonald, S. D. (2020). Demographic, organizational, and clinical practice predictors of US psychologists’ use of telepsychology. Professional Psychology: Research and Practice, 51(2), 184. Link: https://telehealth.org/telephone-telehealth/?utm_source=ActiveCampaign&utm_medium=email&utm_content=New+COVID-19+FCC+Telehealth+Grant+%7C+TBHI+Telehealth+News+4%2F14%2F21&utm_campaign=April+13th+Newsletter&vgo_ee=L60XUD6gIFzXzaAzbkkf6r35hO7C%2FF3J%2FgQB9Uu3XAY%3D Previous rulings for COVID-19 Telephone Telehealth Reimbursement: https://telehealth.org/reimbursement-covid-19-telephone/ < Previous News Next News >

Updated Version of CONNECT for Health Act Introduced in Congress Center for Connected Health Policy May 4, 2021 Last week an updated version of the CONNECT for Health Act was introduced in Congress. Last week an updated version of the CONNECT for Health Act was introduced in Congress. The bill, which was first introduced in 2016 but has been repurposed in this newest version to remove restrictions on telehealth for mental health, stroke care and home dialysis in certain circumstances. It also addresses several of the restrictions in Medicare, including geographic limitations, expanding originating sites to include the home, restrictions on federally qualified health centers (FQHCs) and rural health clinics (RHCs) reimbursement and gives the Secretary of Health and Human Services the ability to waive other telehealth restrictions permanently. For more information, see the press release, or read the bill’s summary published by Senator Schatz office. Stay tuned for a deeper dive and further analysis from CCHP next week. Press Release: https://www.schatz.senate.gov/press-releases/schatz-wicker-lead-bipartisan-group-of-50-senators-in-reintroducing-legislation-to-expand-telehealth-access-make-permanent-telehealth-flexibilities-available-during-covid-19-pandemic Summary: https://www.schatz.senate.gov/imo/media/doc/CONNECT%20for%20Health%20Act%20of%202021_Summary.pdf < Previous News Next News >

OIG Looking Closely at Telehealth as it Weighs Future Enforcement Mike Miliard, Healthcare IT News August 2021 In a HIMSS21 session with updates on the HHS inspector general's oversight and compliance efforts, officials said they plan to ensure virtual care is provided with integrity, and will take aim at telehealth fraud schemes. The Office of Inspector General for the U.S. Department of Health and Human Services works to ensure the integrity of federal healthcare programs and to safeguard the health and welfare of those programs' beneficiaries. In a session at HIMSS21 on Tuesday, two HHS OIG leaders offered a look at the enforcement priorities the agency has in mind these days, and some hints about the compliance responsibilities healthcare organizations should be prioritizing in the coming months. OIG claims to recover three taxpayer dollars for every dollar it spends, and recoups billions in misspent money every year. Speaking via webcam, Lisa Re, assistant inspector general of legal affairs at OIG, offered an update on some of the legal liabilities and risk areas in the health IT space, related to the False Claims Act, the Anti-Kickback Statute and the Civil Monetary Penalties Law. She recounted some of the agency's enforcement actions in recent years, with companies such as athenahealth, CareCloud, eClinicalWorks and Practice Fusion required to pay millions to settle cases. Andrew Vanlandingham, senior counselor for Medicaid Policy and acting health IT lead at OIG, called attention to recent revisions to safe harbors under the Anti-Kickback Statute and Civil Monetary Penalty Rules around coordinated care. He also highlighted a major new priority at OIG: telehealth. "As policymakers, we want to look at what telehealth might look like after the pandemic," said Vanlandingham. "All of those questions are centered around where do they plan on taking this? How will this impact their expenditures for healthcare programs? How to make sure that patients are getting good quality care from telehealth? And I think it's important for us to recognize that we don't know a whole lot right now." He said the OIG is guided by a philosophy summed up in a quote from HHS Principal Deputy Inspector General Christi A. Grimm: "It is important that new policies and technologies with potential to improve care and enhance convenience achieve these goals and are not compromised by fraud, abuse or misuse." When new technologies such as telehealth – with huge upside, but also potential risks – become more commonplace, "it's up to OIG and other healthcare stakeholders to make sure they do live up to that promise and aren't compromised by fraud, abuse or misuse," said Vanlandingham. "And we recognize that a lot of folks in the audience are doing just that: implementing telehealth so it works for patients, for the providers, and is a good tool to enhance care." He said OIG is "working hard to assess how telehealth utilization changed during the pandemic – what that means for corporate integrity, what that means for access, what that means for health equity. We have roughly eight audits and studies ongoing right now that we hope will really be the first down payment for OIG to be part of the broader conversation about what telehealth will look like after the pandemic." The goal is to "help the health technology community and providers as they continue to refine their development of telehealth and enhance virtual care," he said. "This is going to be a whole-of-government and whole-of-industry approach," he added. "It's really up to us to make sure that, since we are at this early stage of implementation of telehealth, that we can avoid issues to make sure that this works as intended, and really ensure that it drives the efficiency and effectiveness and really improves healthcare for all Americans." There have already been some ripe areas for enforcement, said Vanlandingham. "We've had several large-scale national takedown actions involving telefraud schemes with sham or fake telehealth companies," he said. (One of them occurred just this week.) "No one is billing for those telehealth visits fraudulently. They're not submitting a telehealth claim to Medicare. Instead, sophisticated criminal organizations are partnering with telemarketing companies and sometimes unscrupulous doctors to essentially cold call Medicare beneficiaries, get them online with a doctor. And the doctor [asks] a few questions, and then will forge or prescribe expensive equipment that Medicare will pay for durable medical equipment like back braces, or even genetic testing that beneficiaries don't need." DME fraud has been around since Medicare started reimbursing for it, of course. "But for these schemes, what used to be, let's say, $30 or $40 million dollars, maybe $100 million dollars, you've really seen an explosion of exploiting this virtual care model to really bill for a large amount of fraud," said Vanlandingham. "One scheme went for $1.6 billion, with a B, of alleged fraud. So that's obviously very alarming." No one quite knows yet what "telehealth 2.0" will look like, he said. "But I think it is a good example that, as we expand telehealth, there are likely to be instances of large-scale criminal activity that takes advantage of this. And it's up to OIG to assess those risks, and inform policymakers and stakeholders of those risks, and then from those policymakers and stakeholders to adjust." OIG's job now, he said, is to decide "how we can better increase oversight and enforcement to make sure that whatever Congress, CMS and others should decide about how telehealth should be used as providers continue to adopt it, that we've got safeguards to maximize the benefit of telehealth for patients and providers." < Previous News Next News >

Telehealth and Maternal Mental Health Needs Two recent studies show telehealth can help new and expectant mothers. Psychology Today April 30, 2021 Telehealth measures decreased prenatal distress, pregnancy-related anxiety, and postpartum depression. Telemedicine has skyrocketed since the start of the pandemic. According to The New York Times, just short of May 2020, the Johns Hopkins neurology department was seeing 95 percent of patients virtually. The rise in telemedicine to address maternal mental health has also seen unprecedented growth during the pandemic. Meanwhile, Mental Health America states that the mental health needs of Americans have skyrocketed. Anxiety and depression screenings increased nearly four-fold in 2020, from nearly 2,000 screenings per day to roughly 8,000 per day. Women, and in particular pregnant women, are vulnerable to hormonal fluctuations that make them twice as likely to experience depression during their lifetime compared to men. Research in the past year and a half has shown that telehealth can be substantially as effective as in-person care. (Telehealth, more encompassing than telemedicine but inclusive of it, may include only educational components.) With respect to maternal mental health, there are two studies highlighted herein that demonstrate telehealth's promise when it comes to improving maternal mental health in terms of prenatal distress, pregnancy-related anxiety, and the postpartum period. Of note, one of the studies was conducted prior March 11, 2020, or the official start of the pandemic, which makes it non-COVID-19 related. Maternal mental health, or perinatal mental health, is defined by the Maternal Health Task Force as a woman’s mental health during pregnancy and in the postpartum period. The significance of this period is multifold. It includes increased risk of the following: preterm delivery, low birth weight, impaired postnatal infant growth, insecure infant-mother attachments, and suboptimal breastfeeding practices. The first study published in Midwifery in 2021 supports the use of tele-education in improving prenatal distress and pregnancy-related anxiety. Specifically, the Midwifery study showed that “tele-education offered to the pregnant women on pregnancy and birth planning during COVID-19 decreased their prenatal distress and anxiety levels.” What the pregnant women received were phone calls, text messages, and a digital education pdf file, all of which educated women on a variety of topics, including “general methods of protection from coronavirus, coronavirus prevention methods during pregnancy, coronavirus and delivery process, measures to be taken during the coronavirus pandemic and postpartum process, measures to be taken during the coronavirus pandemic and breastfeeding, and how to manage stress, anxiety, and depression in these processes.” The tele-education included a digital pdf file called the “Booklet for Pregnancy and Birth Planning Education during Coronavirus (COVID-19).” All the of the educational content was developed with suggestions from medical and public health experts. A major takeaway from the above Midwifery study is that tele-education is effective in reducing the fears pregnant women have about giving birth as well as about their babies’ health in the context of a pandemic; in summary, prenatal distress and pregnancy-related anxiety were significantly decreased (p-value <0.05). Significantly lower scores on pregnancy-related anxiety questionnaires developed by van den Bergh (1990) and revised by Huizink et al. (2016) demonstrated the effective role played by tele-education. The second study published in Midwifery in 2021 supports the use of telemedicine interventions in treating postpartum depression symptoms. While the study’s timeframe was not during COVID, the results are helpful in understanding the beneficial role telemedicine has played in the past couple of years. Previous research has shown it can be a challenge for postpartum women to seek care for the “baby blues” or depressive symptoms, either of which could be significant. This may be due to perceived stigma, time, financial constraints, transportation, or childcare concerns. In this study, the telemedicine modalities included: telephone support, mobile applications, social media, and websites. This meta-analysis reviewed at least seven randomized controlled trials that largely used cognitive behavioral therapy (CBT) or psychoeducation to help pregnant women participants. The second Midwifery study concluded that telemedicine interventions “significantly decreased postpartum depression symptoms” and “demonstrated feasibility and acceptability among mothers in the postnatal period.” A major takeaway from the second Midwifery study is that telemedicine appears to be “promising in preventing and improving postpartum depression.” Of note, the study looked at women without a history of mental health conditions. Meanwhile, Hanach et al. highlight the need for larger-scale, future research to figure out the structure, content, and type of providers recommended within future telemedicine interventions. In conclusion, the benefits of telehealth—especially during COVID-19—appear to help women in the prenatal and postpartum phases of pregnancy. While the research is still growing, and quite limited, such positive signs are helpful in understanding the role that technology can play in addressing maternal mental health needs. Future studies that reflect on the benefits of telehealth are vital and will be particularly useful in supporting new and expectant mothers, especially in times of adversity. Source: https://www.psychologytoday.com/ca/blog/healthy-mothers-healthy-families-and-healthier-world/202104/telehealth-and-maternal-mental < Previous News Next News >

New Coding Modifier Offers Opportunity To Investigate Audio-Only Telehealth Alexander Beschloss, Ryan Van Ramshorst, Chethan Bachireddy, Christopher Chen, Andrey Ostrovsky November 18, 2022 Prior to the pandemic, Medicaid program coverage of audio-only telehealth services was limited. During the early stages of the pandemic, Medicaid beneficiaries were significantly less likely to complete telehealth visits compared to commercially insured patients. This was likely due to a series of obstacles, including: lack of access to high-quality broadband, a device with video capability, requisite digital skills, and private space to conduct the visit. For example, in 2019, roughly one in four Medicaid enrollees lived in a home without internet or with limited computer access. That said, Medicaid beneficiaries do not have significantly less access to devices with video capability (such as smartphones) than other patient populations, suggesting network connectivity poses more of a barrier than device access. Even further, nearly 50 percent of low-income patients in the US may not have requisite digital health literacy to use virtual telehealth. However, considering that 86 percent of Medicaid beneficiaries own a smartphone, it may be inferred that many more have sufficient digital literacy to engage in audio-only care rather than audio-visual telehealth. Network connectivity and low rates of digital literacy are two barriers that highlight the importance of creating the infrastructure to deliver and measure audio-only visits is of increased necessity. It was in this context that, once the pandemic struck, Medicaid agencies changed policies to augment access to telehealth services. For example, 17 state Medicaid agencies expanded reimbursement to include multiple modalities of telehealth, including audio-only. These changes particularly supported patient populations who had transportation, childcare, employment, or income barriers that prevent in-person care—challenges that are more prevalent in the Medicaid population. These policy innovations narrowed the reimbursement gap among in-person, audio-only, and audio-visual visits. In fact, the Department of Health and Human Services (HHS) recently investigated differences in patient populations who receive telehealth audio-only versus audiovisual use in 2021. For telehealth visits, Medicaid beneficiaries were more likely to use audio-only care than were privately insured patients (35.1 percent versus 45.5 percent). They discovered that compared to White patients, who used audio-only care for 38.1 percent of their telehealth visits, Latino, Black, and Asian patients did so at rates of 49.3 percent, 46.4 percent, and 48.7 percent, respectively. Patients with less than a high school education used it at 61.9 percent of their telehealth visits, compared to those with greater than a bachelor’s degree, who did such at a rate of only 32.6 percent. Across income brackets, there is an inverse relationship between household income and audio-only telehealth use. As the use of audio-only telehealth became more widespread among Medicaid beneficiaries, state Medicaid leaders needed a mechanism to measure clinical outcomes, health care costs, and patient experiences related to audio-only telehealth. Providers also needed a dedicated billing construct that could be used across public and private payers to streamline billing processes. Until recently, such mechanisms simply did not exist. And so, due to these insufficient coding constructs, several Medicaid medical directors spearheaded an application to the American Medical Association (AMA) to create a Current Procedural Terminology (CPT) modifier that would specifically designate audio-only services. In September 2021, the AMA CPT Editorial Panel accepted the addition of the CPT Modifier 93 code for synchronous audio-only telehealth, and the code became active on January 1, 2022. This article provides an overview of the rationale for and process of creating the CPT Modifier 93 code. Potential Benefits Of Audio-Only CPT Modifier Why was the creation of a new audio-only modifier necessary? Several reasons: data collection, policy implementation, health care equity, widespread need, and service specificity. The CPT 93 modifier permits differentiation among audio-only, audiovisual, and in-person care at the administrative level, which subsequently allows health service researchers to monitor and evaluate the use and clinical efficacy among these methods of care delivery. Prior to the introduction of this modifier, such high-quality analyses were impossible to do at scale. Along with the increase in all modalities of telehealth use since the COVID-19 public health emergency (63 fold increase year over year between 2019 and 2020), a survey performed by HHS (across all 50 states and the District of Columbia) discovered that 45.5 percent of all telehealth usage amongst Medicaid beneficiaries was audio-only. Taking things one step farther, several state legislatures including Washington, Connecticut, and New York have recently passed laws mandating or allowing coverage for audio-only services. Audio-only telehealth is being highly used, therefore having a mechanism to collect related data is vital. Implementing this modifier will serve as a tool for policy makers to make informed adjustments in policy around patients who use audio-only services. Implementation of this modifier will also enable claims-based research to monitor for disparities between audiovisual and audio-only care to ensure that all modalities of telehealth are provided in a sustainable, equitable, and high-quality fashion. Additionally, because different states have implemented varying strategies to cover audio-only services during the COVID-19 public health emergency (PHE), the CPT 93 modifier will help health services researchers and policy makers discern the differences between coverage approaches, information that will be crucial in standardizing telehealth data collection/storage across states. From a coding perspective, adding an audio-only modifier to existing and widely used CPT codes is a far more feasible option than alternatives such as individual payers developing their own coding modifiers. That approach would become unreasonably burdensome on providers who would subsequently have to learn and bill using the system established by each payer. Previous Codes Did Not Suffice While CPT codes for services provided through telephone exist, they do not specify the enormous range of behavioral health services, therapies, maternity-related care, post-operative guidance, and other services that have been successfully delivered via audio-only technology since the COVID-19 PHE. For example, CPT code 99441 represents a “telephone evaluation and management service; 5–10 minutes of medical discussion,” which gives no specificity regarding what type of care was delivered. In comparison, the CPT 93 modifier can be attached to theoretically any billing code that is permitted under law, thus allowing for more precise tracking and more useful follow-up research. Prior to the introduction of the CPT 93 modifier, there were seldom CPT codes that could be used to represent audio-only telehealth for specific services. Even though audio-only telehealth has been delivered at high rates, states have only been able to use temporary or workaround solutions to bill for audio-only services. For example, the Healthcare Common Procedure Coding System (HCPCS) Level II code for crisis response (CR) has been used by some states to support audio-only services during the COVID-19 pandemic. In the two and a half years since the pandemic began, however, the use of audio-only to provide health services has become normalized and may in fact now be expected by Medicaid providers and beneficiaries—a reality for which the CR code, and its temporary application, was not designed. The CPT 93 solves this challenge on a national scale. Another prior attempt to capture audio-only telehealth was the CPT modifier 95 that only indicated a telehealth service and did not differentiate between audio-only and audio-visual care. HCPCS Level II code “G0” has also been used; however, it indicates a telehealth service for diagnosis, evaluation, or treatment specific to symptoms of an acute stroke. Furthermore, CPT code 99401 can be used to reflect counseling services that may be provided via audio-only care; however, this code failed to capture all the nuance of the amount of time of care was delivered. At the end of the COVID-19 PHE, the Centers for Medicare and Medicaid Services (CMS) plans to add the “FQ” modifier on claims for HCPCS code G2080 for counseling and therapy provided using audio-only telecommunications. The HCPCS G2080 code refers to when one provides therapy services that largely exceed the amount listed in the patient’s individualized treatment plan for medication assisted treatment for opioid use disorder. This modifier exists solely for CMS’s Opioid Treatment Program and fails to account for other indications for audio-only telehealth. Creating a CPT modifier that is applicable to all service types simplifies the codification and measurement of audio-only care across all payer types. Conduct More Research On Audio-Only Telehealth Researchers, provider organizations, and policy makers must investigate and ensure that audio-only telehealth drives strong clinical outcomes. Telephone-focused care has been an important part of primary care; however, much of it was after hours, unmeasured, and not reimbursed. There is strong evidence on audio-only telehealth’s efficacy in prenatal visits and insomnia, for example. A randomized clinical control trial in a patient population of the Kaiser Permanente Washington system received audio-only cognitive behavioral therapy through the telephone demonstrated a significant benefit in improving sleep, fatigue, and osteoarthritis-associated pain. A cohort study amongst pregnant women in the Parkland Health System in Texas found that audio-only perinatal visits were not associated with changes in perinatal outcomes when compared to in-person visits in a vulnerable population. While these data are encouraging, they are sparse. Measurement of a CPT modifier may streamline the research methods used in these studies. Researchers must continue to investigate the efficacy of specific therapies when delivered via audio-only modalities. While audio-only telehealth solves several problems in health care, there are also several risks such as its potential use for inappropriate clinical indications and the risk that some may see an opportunity to overbill. An audio-only modifier—and therefore a more granular characterization of telehealth modalities—may help assuage concerns about fraud, waste, and abuse, removing existing ambiguity about the impact of different telehealth modalities on outcomes. We also know that the quality and value of these delivery modalities may vary according to the different demographics being served, including factors such as age, insurance status, payer, income, and region, among many others. Such modalities will likely vary between acuity of patient’s indication for care. Only by studying these differences amongst modalities and the populations served, can we ensure that the care delivered is equitable and valuable. Implementing the 93 modifier is a vital step toward enabling health services researchers to urgently pursue research questions that inform evidence-based policy about the best use of audio-only telehealth—especially amongst the Medicaid population. It is also essential to ensuring that the growth of audio-only health care does not create a two-tiered system between private insurance and Medicaid. For example, audio-only care may in fact be lower quality or lower value compared to audiovisual care or in-person care—although, further investigation is necessary to understand these differences. Considering that audio-only care helps remove barriers to care for underresourced patient populations, inappropriate use of audio-only care may further exacerbate the already large inequities in health care—a concern raised by both clinicians and patients. This reliance on audio-only care may also hamstring innovations that can improve the quality and access to audiovisual telehealth or in-person care. Clearly, there are legitimate concerns about the equity of audio-only health. To resolve them, more precise data and extensive investigations are necessary: Both of which will be enabled by the implementation of the CPT 93 modifier. An Opportunity For Action The new audio-only CPT 93 modifier provides meaningful potential benefits to combat barriers to care that were compounded during the COVID-19 pandemic. The new code creates a potent opportunity for conducting rigorous research into audio-only telehealth to inform federal- and state-level policy around equitable telehealth delivery. But to make the most of this opportunity, regulators, payers, providers, and researchers must take steps to increase adoption and evaluation of the audio-only modifier. To catalyze this work, large health systems should consider leading the adoption of the CPT 93 modifier while also encouraging local private providers to do the same. Payers and purchasers should consider requiring modifier submission, a step that would also facilitate further research into the field with minimal additional administrative burden on providers. Federal health agencies have a role as well. For example, the Agency for Healthcare Research and Quality (AHRQ) may increase awareness of the modifiers amongst affiliated researchers or those who use AHRQ databases while the Health Resources and Services Agency may require community health centers they fund to use the new modifier. Authors’ Note The authors would like to thank Dr. John Morgan and Amanda Brodt for their contributions to preparing this paper. Dr. Ostrovsky is an investor in the following companies, some of which provide telehealth services: https://www.socialinnovationventures.com . However, there are no direct conflicts of interest. See original article: https://www.healthaffairs.org/content/forefront/new-coding-modifier-offers-opportunity-investigate-audio-only-telehealth#.Y3feKa9vXhA.twitter < Previous News Next News >

What an eventual end to the PHE would mean for telehealth Andrea Fox October 17, 2022 Among other impacts, ending the PHE would represent access challenges and a loss of Medicaid coverage for millions, and would end medication-assisted treatment for opioid use disorder without an in-person exam. Since the COVID-19 public health emergency was declared in 2020, the Department of Health and Human Services has renewed the legislation every 90 days. Close to the end of the most recent expiration date, October 13, HHS Secretary Xavier Becerra again signed a renewal determination and it was posted without announcement late in the day. There had been no official news, but a lot of hearsay that the PHE would be renewed once more, because the Biden Administration indicated it would give two months' notice before its expiration. There is also the matter that open enrollment begins on November 1, and without the relaxed enrollment provisions for Medicaid that the PHE provides, the national uninsured rate along with health premium costs would certainly rise. But by definition an "emergency" can't last forever. The inevitable end of the PHE could result in the loss of Medicaid to millions when states review enrollee eligibility and in other impacts to healthcare operations. Questions regarding what will happen to telehealth benefits and the continuum of care in the absence of the PHE loom large. There has been extensive support for making the changes that have launched telehealth and provided the opportunity to serve more patients, but some people want to halt the prescribing of controlled substances via telehealth for mental health and substance abuse disorders and see the Ryan Haight Act – the online pharmacy consumer protection act of 2008 – reinstated. What's at stake Despite the Consolidated Appropriations Act of 2022, which provides a 151-day extension on some flexibilities granted during the COVID-19 public health emergency once the PHE ends, providers and other healthcare professionals engaged in telehealth are eager to prepare for the expiration date. There has been mounting pressure from the Republican Party, including a September 19 letter from Sen. Richard Burr, R-N.C., with numerous questions about ending emergency powers after President Joe Biden remarked during his September 60 Minutes appearance that "the pandemic is over." "Without a clear plan to wind down pandemic-era policies, the deficit will continue to balloon and the effectiveness of public health measures will wane as the American people continue to be confused by mixed messages and distrust of federal officials," wrote Burr. Despite economic concerns, ending the legal waivers afforded under the PHE could ricochet, hammering against gains made in increased patient access. Dr. Adrienne Boissy, Qualtrics chief medical officer (and former Cleveland Clinic chief experience officer), notes that patients continue to rely on expanded digital access as mental health effects from the pandemic linger. She says that a reversal would limit digital health access, which an overly burdened and understaffed industry has come to rely on. "The ease and convenience telehealth provides are consistent sources of positive patient experiences, as well as decreased total costs of care and less time away from the workplace," she said in a statement to Healthcare IT News. "Comparing 2016 to 2022, clinicians also report better health outcomes for patients, efficiency and less stress/burnout as major drivers for adopting digital tools, including telehealth," she said. "With the PHE, we saw the industry put patients and their access to care first – no longer hindered by location or demographics. "To revert back to reimbursement models that only support in-person care unravels the gains of meeting people where they are – physically and emotionally," said Boissy. "We can’t turn back now," Boissy said. Brad Kittredge, CEO and cofounder of Brightside Health, adds that the country will be short of psychiatrists – by 14,280 to 31,109 – in just a few years. Ending the PHE presents a reduced ability to serve the growing number of patients in need of or seeking mental healthcare, he said. "While there’s no silver bullet solution, telehealth offers the best and most immediate solution to this growing challenge by increasing patient access to mental health specialists without being limited to geographic regions or facilities," Kittredge explained in a statement sent to HITN. "More significantly, telehealth enables us to use technology and data to help clinicians be more efficient and effective at treating their patients, maximizing the impact they can make," he said. Telehealth in legislative limbo During a recent American Telemedicine Association policy update, the ATA's federal and state-level telehealth policy experts described efforts to develop a consistent regulatory framework so telehealth can be deployed across states, be fully leveraged and address the patchwork of 50 different state requirements. Legislators have also proposed broadening access to telehealth through the Telehealth Benefit Expansion for Workers Act, the Telehealth Extension Act and the Advancing Telehealth Beyond COVID-19 Act of 2021, which was passed by the House of Representatives in July, received in the Senate and referred to the Committee on Finance, where it sits. Also at play are a number of loosened restrictions that opened the gateway to online treatment of certain conditions when uptake surged and access to in-person medical care was restricted. Healthcare organizations and retailers entering the space through mergers and acquisitions with healthcare providers have urged the U.S. Justice Department and the Drug Enforcement Agency to revise telehealth controlled substance rules. The bill H.R. 7666 – the Restoring Hope for Mental Health and Well-Being Act of 2022 – introduced by Rep. Frank Pallone Jr., D-N.J., which was passed in the House, aims to address this hot-button issue for mental telehealth providers. The bill would permanently eliminate the X waiver, currently not required under the PHE. To qualify for the waiver to dispense buprenorphine for maintenance or detoxification treatment, the practitioner must take an eight-hour training and may only treat up to 30 opioid use disorder patients. Dr. Kristin Mack, a physician in Ticonderoga, N.Y., told MedPage Today that she would like to see the X waiver eliminated permanently. According to the story, rural communities are some of the hardest hit by the opiate epidemic. "We work really hard with community resources to provide counseling and things like that. But if I were to tell somebody, 'Oh, you have to go an hour away to a city to get care for this,' and then they need to be seen monthly, it's just not an option," she said. The Restoring Hope for Mental Health and Well-Being Act of 2022 was received in the Senate and was referred to its Committee on Health, Education, Labor and Pensions at the time of reporting. Treating opioid use disorders via telehealth It has been more than 10 years since the Ryan Haight Act mandated that DEA establish a rule ensuring that healthcare providers can successfully prescribe controlled substances via telehealth, but there has been no rule set forward. The SUPPORT Act again mandated the DEA issue rulemaking by October 2019 and the fiscal year 2021 final appropriations report requested that the agency establish these rules, according to the website of Sen. Mark Warner, D-Va. This past year he urged the Biden Administration to finalize regulations that allow doctors to prescribe controlled substances through telehealth. "In practice, the DEA’s failure to address this issue means that a vast majority of healthcare providers that use telehealth to prescribe controlled substances to and otherwise treat their patients have been deterred in getting them the quality care they need. These restrictions have been temporarily waived during the COVID-19 public health emergency, and I welcome that, but patients and providers need a more permanent and long-term solution to this long-delayed rulemaking," Warner wrote in May 2021. Under the PHE, several virtual behavioral health startups focused on medication-assisted treatment for substance abuse disorder received investment rounds, according to Chris Larson at Behavioral Health Business. According to the story, Doug Nemecek, the chief medical officer of behavioral health for Evernorth, said that not enough people are accessing MAT, and that overdose rates have reached historic highs. "If regulations come back that prevent those companies from being able to deliver care in that way, we’re concerned that it’s going to have a negative impact on patients and our ability to make sure that people have access to the MAT that we want them to have access to," Nemecek said. Evernorth, part of Cigna Corp., is connected to digital MAT companies like Quit Genius. The cofounder of Quit Genius, Dr. Maroof Ahmed, explained in an email to Healthcare IT News that telehealth has filled a void that existed before the PHE. "Telehealth flexibilities and ePrescribing waivers have been crucial in enabling providers to care for patients during the pandemic and have greatly expanded access to care in situations where patients were unable or unwilling to travel to a physical location," he insists. Reinstating Ryan Haight Act requirements also has support Amending the Ryan Haight Act law is an effort largely supported in the healthcare and mental health space. However, Dr. Mimi Winsberg, CMO and the other cofounder of Brightside Health, shared another point of view regarding the dubious practice of prescribing controlled substances without an initial in-person visit. "To count on a public health emergency temporary lifting of laws in order to stimulate growth of your business is perhaps a questionable practice," she told Healthcare IT News, noting that Brightside adhered to not prescribing controlled substances over telemedicine despite the legal waivers. "While a lot of medical visits moved to tele during this sort of difficult part of the pandemic, that now in most specialties, they have gone back to in-person, but what we are seeing in mental health is about 80% have stayed remote," she added. "And so patients are continuing to get their mental healthcare largely through telemedicine." Winsberg entertained the question out loud: "Will they be resistant to in-person appointments if they need certain kinds of prescriptions?" "I don't think they will because we have seen that they're willing to go back to the doctor for other reasons," she added. The net growth of prescription drugs issued – stimulants and other controlled substances – grew during the pandemic, and she says she questions if the growth was largely driven by online practices "that were taking advantage of the lifting of the Ryan Haight Act." Winsberg did acknowledge, however, that an inability to prescribe buprenorphine via telehealth for substance abuse disorder, "is potentially an issue," she said. "These laws exist for a reason, and what we have to balance in medicine is the willingness to help people with the do no harm principle." Establishing systematic monitoring of controlled-substance prescribing via telehealth could be achievable, Winsberg said. "But, we'd like to move towards appropriate prescriptions of controlled substances, and if we can find a way to meaningfully regulate that online, then great," she concluded. Equal treatment for mental health disorders In January, Dr. Robert Field and doctoral candidate Kimberly Williams at Drexel University published a commentary on the National Academy of Medicine website on the long overdue policy update needed to prescribe buprenorphine via telehealth. The authors say that those who need treatment for opioid use disorder should have the same level of telehealth access as others who receive treatment for other medical concerns. They also noted that the DEA has not created a registration process through the online pharmacy consumer protection act, despite Congressional requests and statutory actions. "Doing so would not only ensure increased access to treatment but also set the stage for systematic monitoring of telemedicine and telephone services to confirm they meet the same rigorous standards of care as in-person services. "Such quality assurance efforts could promote the development of best practice guidelines and reduce variations in care as usage of these modalities increases," they argue. For the mental telehealth provider community wondering if the ability to prescribe buprenorphine via telehealth fades away in five months – if the Biden Administration does not intervene and extend the PHE, Congress does not pass legislation and the DEA does not create a registration process for prescribing controlled substances for opioid use disorder via telehealth – the U.S. may face even higher overdose rates. Andrea Fox is senior editor of Healthcare IT News. Email: afox@himss.org Healthcare IT News is a HIMSS publication. See original article: https://www.healthcareitnews.com/news/what-eventual-end-phe-would-mean-telehealth < Previous News Next News >

Biden’s American Jobs Plan Increases Investments in Broadband Infrastructure Center for Connected Health Policy April 13, 2021 President Biden’s recently released American Jobs Plan includes $100 billion to increase access to affordable, reliable, and high-speed broadband throughout the country. President Biden’s recently released American Jobs Plan includes $100 billion to increase access to affordable, reliable, and high-speed broadband throughout the country. Comparing digital infrastructure today to affordable access to electricity in the 1930s, the Fact Sheet on the Plan released by the White House states how the pandemic has highlighted existing disparities related to the digital divide and the lack of broadband access to more than 30 million Americans. The $100 billion investment will prioritize broadband infrastructure in unserved and underserved areas to reach 100% high-speed broadband coverage. It also sets aside funds for tribal lands and promotes broadband providers less focused on profits, such as those affiliated with municipalities, and seeks to improve price transparency and competition among internet service providers. The plan will include internet subsidies to low-income consumers, but states that in the long-term, the President is committed to working with Congress to reduce internet prices negating the need for such short-term solutions. The full Fact Sheet on The American Jobs Plan can be accessed on the White House website, https://www.whitehouse.gov/briefing-room/statements-releases/2021/03/31/fact-sheet-the-american-jobs-plan/. < Previous News Next News >