Q&A

Washington expert shares insights on which telehealth flexibilities are likely to — and should — become permanent

By Carley Thornell | April 15, 2021

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What happens after the public health emergency is lifted is the question that unites both sides of the aisle in Washington, D.C., says Sarah-Lloyd Stevenson. A Director with Faegre Drinker Consulting representing the American Telemedicine Association — and former senior policy advisor in the United States Senate, HHS, and White House — shared her thoughts on the medical, political, and cultural impact of virtual care in a recent conversation with athenahealth Vice President of Government Affairs, Joe Ganley.

The telehealth landscape has changed so much in the last year. What do you find most promising?

As someone who's been pushing for these reforms for years, it is good to see that we've had a bit of a laboratory to expand access to care during the pandemic, and collect the all-important data that demonstrates how telehealth improves access to healthcare and controls costs. This is something that members of Congress and staff have asked for years: “Show me the data. Show me that costs aren't going to go up.”

The pandemic and stay at home orders created an environment where more patients and doctors relied on telehealth services. What we are seeing is that people want these services to stick around. In the Medicare program, we have over a year’s worth of data to examine utilization, cost, potential for fraud and abuse, and more. We can see what the hypotheticals of years past look like in real life.

As we're talking about ensuring that these flexibilities around telehealth don’t disappear overnight, we also believe that telehealth is not going to replace – nor should it – all in-person services. It will be interesting to see how virtual care and in-person care complement each other in the coming years to improve the wellness of our population.

Who should decide which services are most appropriate for virtual delivery, and which are in-person?

The mindset 20 years ago was that telehealth is good for rural communities. That gave rise to the geographic restrictions on services in place today, and effective right before the COVID pandemic started. I say it should be up to the patient, period. If the patient wants telehealth, and a provider agrees it's clinically appropriate, that service should take place virtually. If the patient doesn't want telehealth, they never should be forced to receive care virtually. It’s all about providing options and flexibilities, not mandates. The American Telemedicine Association believes neither state nor federal government should exclude services based on virtual or in-person.

Where I get concerned is when I'm having conversations with relevant Congressional Committees and staff on Capitol Hill, who say, for example, ‘Physical therapy should not be a telehealth service, let's make sure they're categorically excluded.’ If you talk to APTA (American Physical Therapy Association), they're going to tell you that there is a lot that you can actually do via telehealth. And they have been championing that for years. Again, we believe you have to provide care delivery options in the 21st century, and federal statute should not categorically exclude specific services, locations, or providers.

You’re from Mississippi, which has a large rural population. Is that why telehealth as an option is so important to you?

Because of those rural populations, remote patient monitoring (RPM) was my first foray into telehealth. Mississippi has a lot of individuals with multiple comorbidities who may struggle to manage them without access to providers on a regular basis. If you’re thinking holistically about the patient and what their daily life is like as opposed to going to a provider once a month, RPM is a way to help bridge that. So I’m passionate about it.

Telehealth can be a way to help change the healthcare system. A provider has the ability to stay in contact with the patient more regularly. Incorporating RPM, real-time audio/visual, and in-person visits, all of these together are a comprehensive way of providing value-based care. I think this approach can really help shift our system.

Recent athenahealth research found that telehealth adoption of providers in Mississippi was among the lowest in the U.S. Do you think that’s a cultural shift, or a technical issue — or perhaps both?

I found your research interesting. This likely is a technical problem as many communities do not have access to a reliable broadband connection. During the pandemic, some have said, ‘Oh, well telehealth is bad because it's leaving behind certain populations.' I think that's an unfair assertion, because no, broadband is leaving them behind. For that reason, we need to support the expansion of broadband but also allow reimbursement for audio-only services when an audio-video connection may not be realistic. But there's a lot of work that needs to be done. I think you'll be hard-pressed to find a member of Congress who doesn’t agree with the importance of expanding broadband and expanding access to telehealth.

Typically, the Centers for Medicare & Medicaid Services leads the way in terms of policy and payment, and the commercial markets follow. Is that the same for telehealth?

Fortunately — or not — the federal government doesn't restrict too much as far as the services in the commercial market, and reimbursement. Pre-pandemic, the commercial market was a little further ahead in telehealth service access than Medicare was. It’s a funny thing that I've always thought was pretty backward. A lot of that was because the Congressional Budget Office continued to have cost concerns, while the commercial market has, especially for employer-based plans, recognized, “OK, telehealth is actually very beneficial for our employees. This can keep them at work, keep them healthy, and keep our costs low.”

Do you think reimbursement should and will stay the same, post-public health emergency?

Telehealth reimbursement in Medicare should continue post-public health emergency, but Congress must act to enable this to happen. The Medicare Payment Advisory Commission, “MedPAC,” is a nonpartisan organization created by Congress, with the sole purpose of informing Congress. Twice a year they provide Congress recommendations on specific policies and what they should do. I have a few issues with some of MedPAC's assertions and recommendations in their recent March report, but for the most part, they are good and based on the shared idea that telehealth access must continue post-pandemic. Importantly, they noted that 90 percent of Medicare beneficiaries who responded to their survey had very positive reactions to their telehealth experience during the pandemic. But they also recommended changing that back to a slightly lower rate, as we're moving beyond the pandemic.

I will note that for a provider, regardless of if you are in-person — and especially mental health, where you're really having a conversation with your patients — the review of the patient's files, looking at anything additional post- or pre-appointment, as well as the actual conversation, it requires the same work and intellect, whether you're in-person or virtual.

That's going to be a pretty big conversation, as we're thinking about how services should be reimbursed.

For more insights on the healthcare landscape in Washington, be on the lookout for another edition of the What the Hill? newsletter later this month, or join athenahealth in May for the next Policy Ambassador webinar.

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