For years, states and the federal government have explored how to create opportunities for patients to see a doctor, nurse, therapist or other health care provider online. When the nation went into lockdown due to COVID-19, those efforts sped up to allow a big expansion of telehealth.
Will it hold? Experts who took part in an NCSL telehealth webinar say yes. The panelists note that much is underway to codify and expand many of the temporary pandemic-related changes to telehealth.
“State policymakers are really taking stock of the many telehealth flexibilities they pursued during the COVID-19 pandemic and looking at which of these changes they’d like to continue on for the long haul,” says Jack Pitsor, an NCSL health policy associate who moderated the webinar.
“We have tracked at least 51 enacted bills across 37 states where those states have permanently incorporated those telehealth flexibilities into state law,” Pitsor says.
But that is only a part of the story.
Many states are exploring long-term options, as shown in the NCSL Telehealth Explainer Toolkit. And the federal government is reassessing its role in telehealth, according to Mei Wa Kwong, who is executive director the Center for Connected Health Policy.
Some of the big issues to be resolved for long-term expansion, according to the panel:
- How public and private insurance programs cover online care.
- Licensing for health professionals, especially across state lines.
- What kinds of care should be eligible and when online care is not appropriate.
- How often care providers should meet in person with their online patients.
- How to ensure technology supports access for everyone.
Kwong says there are hurdles at the federal level, and they are no small matter.
“A lot of the telehealth policy changes on the federal level would really require statutory change” of Medicare rules, she says. “You literally need an act of Congress to change a lot of those barriers to telehealth that were waived during the pandemic.”
You literally need an act of Congress to change a lot of those barriers to telehealth that were waived during the pandemic. —Mei Wa Kwong, executive director, Center for Connected Health Policy
Still, she says there’s a lot going on at the federal level short of acts of Congress.
For one thing, the Centers for Medicare and Medicaid Services has authority to make some changes through how it sets physician reimbursements.
CMS has extended some of the temporary telehealth measures to 2023 to gain more evidence on how they work. The agency has also expanded options for telehealth for mental health services so that patients can access care from home rather than going to a treatment center, and they can have treatment by audio-only telephone consultations.
Kwong says this is a significant change.
“Before COVID-19, I think most of your states probably excluded audio-only from being under the umbrella of telehealth,” Kwong says. “The thinking was, ‘This does not count as telehealth.’”
But once the pandemic stirred things up and dramatically increased the need for mental health services, coverage for audio-only therapy began to look viable to CMS, she says.
“They felt comfortable this was a way services could be provided to the patient and also there was a great need for mental health services,” Kwong says.
The pandemic also challenged another long-held rule about telehealth: that health care providers should be licensed in each individual state where they practice, which has been a barrier to serving patients in other states. That’s changing.
Medicare has eased the requirement that patient and doctor need to be geographically close for mental health care, though it has instituted a requirement that they see each other for an in-person visit every six months.
And a few states have taken a big step and said providers from elsewhere are welcome to serve their residents through telehealth, albeit for limited kinds of medical services. Before COVID, that simply wasn’t allowed in most states.
Vermont Senator Virginia Lyons (D) says her state embraced that concept, citing as an example the way college students can continue their mental health care without interruption when they return to the state.
Arizona passed a package that included expansive audio-only coverage, a requirement that health care providers cover and reimburse for telehealth the same as for in-person visits, an allowance for out-of-state providers to serve Arizona residents online and the establishment of a telehealth advisory committee, among other reforms.
Representative Regina Cobb (R), who sponsored the Arizona bill, had been focused on telemedicine for several years. The pandemic pushed the state in to high gear.
“We were already working on several telemedicine bills before we ever even came into the pandemic, and when the pandemic happened, it seemed like a likely time to implement as much as we possibly could,” she says, adding that Arizona’s pandemic reforms were highly successful.
Vermont also had worked on telemedicine before the pandemic, Lyons says.
“But COVID did emphasize the need for broadband expansion, telephone connection because you can’t always call from there to here in our state,” she says.
Finding Appropriate Care
And that’s also why the state is looking closely at how to continue and regulate the use of audio-only care, as are many others.
Lawmakers want to avoid putting patients at any risk if the phone isn’t an adequate way to assess certain health issues and communicate about them. Lyons says in Vermont, they decided not to allow audio-only psychiatric evaluations to consider whether a patient needed hospitalization.
“We did determine that it would be appropriate for an initial meeting, audio only, for mental health counseling and psychiatry. The reason for that is we are seeing an escalation of adolescent psychiatric issues and we thought this might be a way to help,” she says.
Whatever states do, they’ll need to assess how it’s working and adjust accordingly, the panelists say.
“One of the principles that we put in place during the pandemic that reinforced who we are was that we want to increase telehealth without increasing social isolation and without supplanting local community-based medical services throughout our rural state,” Lyons says. “We want to ensure that we have quality, and we want to be able to measure that quality and access for folks.”
Kelley Griffin is a writer and editor in NCSL’s Communications Division.