This paper summarizes the types of telehealth policy flexibilities provided by states and the federal government during the COVID-19 pandemic and longer-term considerations for Governors regarding the impact of such policies on care delivery and payment with the goal of helping policymakers assess the appropriateness of policy permanence beyond the pandemic.
The onset of the COVID-19 pandemic brought an unprecedented level of attention to telehealth as a mechanism for delivering health care services. The federal government and states provided temporary modifications to many policies to make it easier for health care providers to be reimbursed for services provided via telehealth, which resulted in a significant uptick in services, particularly early in the pandemic. Major changes centered on licensure, scope of practice, supervision, coverage, reimbursement and modalities for delivering services via telehealth.
As states begin to think about long-term policies, policymakers may consider how telehealth impacts access, cost and quality of care. Experience during the pandemic may help justify permanence of some flexibilities, particularly surrounding the types of providers who may be reimbursed, services that are covered and distant and originating sites that are permitted. However, other policies, such as payment parity, may receive less traction, especially given rising health care costs and state budget shortfalls. As states look to incentivize greater provider accountability for outcomes, telehealth flexibilities may be a lever to encourage participation in risk bearing value-based payment arrangements. In addition, there remains significant opportunity to close the digital divide that can exacerbate inequities in health care access for individuals who may experience difficulties engaging in telehealth.
This paper summarizes the types of policy flexibilities provided by states and the federal government during the COVID-19 pandemic and longer-term considerations for Governors regarding the impact of such policies on care delivery and payment with the goal of helping policymakers assess the appropriateness of policy permanence beyond the pandemic.
Health care providers have been providing services via telehealth for decades with increasing levels of technological sophistication over time. However, it was not until the COVID-19 pandemic reached the United States that federal, state and commercial payers created broad flexibility in many telehealth policies to facilitate physical distancing while maintaining access to health care services. In addition to providing a mechanism for individuals to receive care at home, payment parity for telehealth helped many providers stay solvent during the COVID-19 pandemic. As a result, there have been more telehealth policy changes (many of which are temporary) within the past year than in the past 20 years. Further, use of services provided via telehealth has increased dramatically. An analysis by FAIR Health found a 3,806 percent increase in the volume of telehealth claims from private payers from July 2019 to July 2020, which is largely attributed to flexibility and awareness of telehealth during COVID-19. While we cannot assume that the higher uptake of telehealth will continue at the same rate post-pandemic, as patients may have felt they had little choice but to receive services virtually, payers are amassing extensive data upon which to measure outcomes in the short and long-term.
Although the Centers for Medicare & Medicaid Services (CMS) regulates coverage and payment policies for Medicare, and the Drug Enforcement Administration (DEA) sets limitations on teleprescribing of controlled substances, states and territories have significant authority to set telehealth policy in Medicaid, the individual market, and through health professional licensure.
Throughout the pandemic, states and territories have used their authority via executive order, legislation and guidance to allow greater use of telehealth with at least 50 states and territories taking action to temporarily or permanently modify policies. Although at time of publication the federal public health emergency continues and many states are renewing their emergency orders, some states have already started making permanent policy changes. As of November 24, 2020, 23 states have passed telehealth legislation that extends beyond COVID-19.
Across states, there is wide variation in telehealth policies. This differentiation also extends to policies within states by payer. In many instances, health care providers treat patients covered by several different payers, meaning that they must comply with a range of different telehealth policies.
This issue brief is intended to help Governors, regulators and legislators evaluate telehealth policies beyond the pandemic.
Key Considerations for Governors
The following considerations can help Governors and their teams assess the potential implications of different policies:
- Licensure policies can be used to facilitate interstate practice and the range of health care professionals for whom such practice is permitted, including required supervision.
- Coverage of services provided via telehealth may be narrowly defined by policymakers or broadly defined to allow providers flexibility to determine when telehealth is appropriate.
- Pairing payment policies and incentives to move towards more value-based models may serve as a lever to support appropriate use of telehealth without increasing costs to the health care system.
- Establishing policies that narrow the digital divide will increase accessibility for those who may have difficulty engaging in services via telehealth such as rural and low-income communities, people with disabilities, people with limited English proficiency and people with mental illness.
- Encouraging interoperability of telehealth platforms with other health information technology presents an opportunity to streamline processes and improve information sharing and care delivery.
- Ensuring policies account for appropriate privacy protections without limiting access to care can improve protections for consumers.
- Engaging stakeholders can be an important process for engaging subject matter experts, health providers and community members to inform telehealth policy development.