Overarching Issues

Telehealth demonstrated during the COVID-19 public health emergency that it can improve access, safety, convenience, efficacy and patient’s experience of care. Telehealth is the natural evolution of healthcare into the digital age—it is not a different type of care, but a different site of care. As such, we should not hold telehealth to higher standards than other care sites, and we should trust clinicians providing telehealth services to triage patients needing a higher level or care or in-patient care, as we do in other care settings. As is done in other care settings, patients’ preference for obtaining care in-person or via telehealth should be respected.

This raises important questions about many previous telehealth restrictions, such as prohibiting reimbursement for visits originating in patients’ homes and allowing limited types of conditions and providers to utilize telehealth under traditional Medicare, such as behavioral clinicians and physical therapists. Many—but not all—policy changes that temporarily lifted restrictions during the pandemic should become permanent. There are better ways to address FWA concerns and telehealth‘s appropriateness in various situations that drove the previous restrictions.

For example, requiring clinicians and other providers to have a previous, in-person relationship with patients can inhibit needed access to care and is not consistent with most state-level or value-based payment policies. Similarly, blanket bans on audio-only can exacerbate disparities for patients lacking video technology or broadband access. Asynchronous modalities such as remote patient monitoring (RPM) may also be appropriate for services that do not require real-time interaction.

Strict limits on providing telehealth across state lines that were waived during the pandemic also do not appear warranted. States have a patchwork of requirements for obtaining and maintaining a medical license that burdens physician and other health professionals and make it difficult for clinicians to practice telehealth in multiple states – even when those states are contiguous or share a metropolitan area.

Waiver of these restrictions allowed for additional surge capacity, dramatically lessened wait times for telehealth visits, and helped triage many conditions that might otherwise have resulted in unnecessary in-person care that put patients at risk. Outside of a pandemic, care across state lines can ensure access to care in places with clinician shortages, allow residents who travel for work or seasonally to maintain consistent doctor-patient relationships, and allow specialized care and expert consultations for those with serious conditions.

There are currently different definitions of telehealth, telemedicine and RPM. A widely agreed upon taxonomy of the various telehealth modalities can help clarify policy.

Finally, policymakers should not expect telehealth to resolve long-standing issues, such as care coordination and the move from FFS to value-based payment, but instead leverage telehealth-related policy development to help address these issues.

American Telemedicine Association Telehealth Taxonomy

The most commonly used approaches in telehealth include:

• Virtual Visits: Live, synchronous, interactive encounters between a patient and a healthcare provider via video, telephone or live chat.
• Chat-based Interactions: Asynchronous online or mobile app communications to transmit a patient’s personal health data, vital signs and other physiologic data or diagnostic images to a healthcare provider to review and deliver a consultation, diagnosis, or treatment plan at a later time.
• Remote Patient Monitoring: The collection, transmission, evaluation, and communication of individual health data from a patient to their healthcare provider from outside a hospital or clinical office (i.e., the patient’s home) using personal health devices including wearable sensors, implanted health monitors, smartphones and mobile apps. Remote patient monitoring supports ongoing condition monitoring and chronic disease management and can be synchronous or asynchronous, depending upon the patient’s needs. The application of emerging technologies, including artificial intelligence (AI) and machine learning, can enable better disease surveillance and early detection, allow for improved diagnosis, and support personalized medicine.
• Technology-Enabled Modalities: Telehealth and virtual care solutions also provide for physician-to-physician consultation, patient education, data transmission, data interpretation, digital diagnostics (algorithm-enabled diagnostic support) and digital therapeutics (the use of personal health devices and sensors, either alone or in combination with conventional drug therapies, for disease prevention and management).

Overarching Issue Policy Recommendations

1. Policymakers should make permanent the following telehealth policy changes enacted during COVID-19 to improve access, patient safety and outcomes:
   1. Removal of strict limits on sites where telehealth visits may originate, conditions clinicians may treat, and which clinicians and providers may use telehealth.
   2. Acknowledging that telehealth visits can establish clinician/patient relationships as long as they meet appropriate standards of care or unless careful analysis demonstrates that, in specific situations, ensuring patient safety, program integrity or appropriate high-quality care requires a previous in-person relationship.
   3. Allowing audio-only telehealth where evidence demonstrates it to be effective, safe and appropriate, or where it is likely to be so and offers access to care that would otherwise be unavailable to a patient.
   4. Allowing asynchronous telehealth (e.g., remote patient monitoring) when it is the preference or need of the patient on a limited basis as more clinical evidence is generated on best practices for ensuring quality, safety and program integrity.
   5. Identifying and implementing policies related to use of these modalities that is based on the evidence of their effectiveness, safety and ability to meaningfully impact access to care.
   6. Allowing insurers to provide telehealth technology, such as smartphones and tablets, as supplemental benefits.
   7. Allowing telehealth across state lines by considering strategies to expedite licensure reciprocity between states, while maintaining important patient protections and disciplinary tools for bad actors.
2. Stakeholders, including policymakers, should agree on a taxonomy of telehealth care that fully describes the range of services and modalities—including types of audio-only encounters—that appropriately aligns standards, quality, payment (as appropriate) and program integrity. Within that taxonomy, policymakers should view “virtual visits” as another site of care rather than as a different type of care.“Part of the infrastructure that needs to be put in place is the capability to work with ethnic communities and other demographic groups, on both sides of the Patient-Clinician relationship, to identify digital literacy and trust gaps that inhibit successful adoption of telehealth.” Regina Benjamin, MD, Founder, BayouClinic/Gulf States Health Policy Center, former U.S. Surgeon General 
3. Broadband and technology greatly facilitate telehealth and contribute to telehealth’s patient safety benefits, but they are not available to or affordable for all patients, particularly rural and underserved populations. Policymakers must promptly expand efforts to ensure universal access to broadband and other needed telehealth technology to bridge these gaps and avoid exacerbating disparities as healthcare moves into the digital age.
   1. Policymakers should assess how to best address patients with specific telehealth challenges, such as those with translation needs or limited visual or auditory capacity, and who lack broadband access.
   2. There also must be contingencies in place to address technology failures.
4. Policymakers should develop and prioritize initiatives aimed at addressing the lack of trust and digital literacy gaps that inhibit successful telehealth adoption for patients, clinicians and other providers—with particular focus on populations that have struggled in the transition to telehealth during the pandemic. Policymakers need to identify groups at highest risk for low digital literacy and partner with patient and consumer groups to implement initiatives to increase digital literacy rates.

5. Policymakers should reinstate full enforcement of HIPAA patient privacy protections.