COLUMBIA, S.C. (WSAV) — As some school districts begin implementing hybrid learning options, many students are still learning remotely.
Experts say the need for better internet access in rural communities is becoming clear as the digital divide worsens.
South Carolina electric cooperatives are urging federal regulators to ensure internet providers bring high-speed access to rural areas.
Members of Electric Cooperatives of South Carolina (ECSC) say the lack of broadband connectivity, compared to urban areas, is deepening disparities in education and the workforce.
“What we see is unemployment, underachievement in our schools,” ECSC President and CEO Mike Couick said. “So many of these things are tied to the lack of quality broadband access.”
The push comes after some providers won a portion of $20.4 billion in federal grants that included new requirements to meet the needs of unserved and underserved areas.
The funding, called the Rural Digital Opportunity Fund, was established by the Federal Communications Commission to encourage the expansion of high-speed internet access to underserved areas to bridge the digital divide.
Electric cooperatives are urging regulators to build for the future, not the present.
“As co-ops, we look at the need for this connectivity. It’s not an eight or 10-year need. It’s an eight to 10-month need,” Couick said. “Our economy is changing. Our home is going to be a schoolhouse. A home is going to be a place of business for a lot longer. Let’s make sure we get it gigged-up to do both of those things.”
“The teachers want the students to download the homework,” Couick said. “They don’t have adequate broadband in their home to do it. There’s no communication of work being done, assigned and graded between the student and the teacher. And they just get further and further behind.”
“We’re taking a sub-generation of children and taking years out of their educational opportunities,” he added.
Co-op leaders note that there is little they can do for consumers in areas where they fail to receive adequate broadband service.
“If you’re in a location where you can’t get quality — quality being that you and your children can both be in your home and do your business and have your school — let your local leaders know,” Couick said.
Two more telehealth bills have returned to Capitol Hill after failing to make it through last year’s session. One takes on kids’ health and other calls for an HHS study of how telehealth has effected care delivery.
– Two more telehealth bills have resurfaced on Capitol Hill, joining a growing package of legislation aimed at improving connected health coverage and access after the coronavirus pandemic.
US Reps. Lisa Blunt Rochester (D-DE) and Michael Burgess, MD (R-TX) last week reintroduced the Telehealth Improvement for Kids’ Essential Services (TIKES) Act (HR 1397), which aims to boost telehealth coverage through state Medicaid and Children’s Health Insurance Program (CHIP) services.
While no text is available for this bill, Rochester and Burgess, who first submitted the bill last October, said last year that it would “provide guidance and strategies” to help states integrate telehealth in Medicaid and CHIP programs and mandate telehealth studies from both the Government Accountability Office (GAO) and the Medicaid and CHIP Payment and Access Commission (MACPAC). It would build upon a 25-page CMS toolkit unveiled in April 2020 that’s designed to help states expand telehealth coverage under Medicaid and CHIP to deal with the pandemic.
“Amidst the pain and suffering that our nation has endured throughout the COVID-19 pandemic, a major takeaway has been the advantage of telehealth,” Burgess said then. “There is a convenience factor to not having to take time to physically transport yourself to the doctor’s office and have your child sit in a waiting room with other potentially sick patients. This bipartisan legislation will improve utilization of telehealth by requiring the Centers for Medicare and Medicaid Services (CMS) to provide guidance to states on how to make the most of telehealth options in their Medicaid and CHIP programs. Additionally, it directs studies to gather data that can help inform future telehealth policy.”
Also making a return appearance in Washington is the COVID-19 Emergency Telehealth Impact Reporting Act (HR 1406), which would have the Health and Human Services Department collect data on telehealth use during the pandemic and analyze how these technology platforms have affected care delivery.
“Telehealth is undoubtedly the future of health care, especially for the rural communities that I am privileged to represent,” US Rep. John Curtis (R-UT), who co-sponsored the bill submitted last July and this year’s version with US Reps. Peter Welch (D-VT) and Doris Matsui (D-CA), said in a press release last year. “Ultimately, Congress’ objective should be to make many – if not at all – of these regulatory changes permanent. Our bill is a significant step in that direction because it will ensure we are keeping patients’ health and reducing the costs of care through value-based medicine as our top priorities as we consider expanding telehealth services throughout the country.”
With the COVID-19 pandemic in full force last year, Congress saw several bills aimed at improving coverage for and access to telehealth services both during the after the public health emergency, but none of those bills made it out to a vote. With a new administration and Congress in place this year, the hope is that some – if not all – of these bills making a return will be approved, either individually or in some sort of package.
The Telehealth Modernization Act codifies crucial flexibilities for telehealth coverage to increase access to high-quality health care services, particularly for seniors.
WASHINGTON— Today, Senators Tim Scott (R-S.C.), Brian Schatz (D-HI), and Jeanne Shaheen (D-N.H.) reintroduced the bipartisan Telehealth Modernization Act that would update coverage restrictions that have long prevented life-saving telehealth services for many of the nation’s roughly 61 million Medicare beneficiaries. They are joined by Senators Blackburn (R-TN), Marshall (R-KS), Tester (D-MT), and Wicker (R-MS).
“As Ranking Member on the Senate Aging Committee, I know how important telehealth is to our nation’s seniors. Telehealth has been a godsend for millions of Americans receiving health care services during the pandemic, while ensuring the spread of the virus stays at a minimum,” said Senator Scott. “Updating our laws to solve today’s challenges through commonsense and practical approaches will ensure more access to health care and a safer aging population.”
“Telehealth has been a critical lifeline for millions of patients who need care during this pandemic. Now we need to make sure that the emergency expansions of telehealth coverage for Medicare beneficiaries are made permanent,” said Senator Schatz. “This new bill works hand in hand with the CONNECT for Health Act by removing unnecessary barriers in Medicare and making it easier to keep using telehealth moving forward.”
While these Medicare access gaps predated the pandemic, the spread of COVID-19 highlighted the urgency of updating telehealth coverage rules, prompting Congress to provide authority for temporary emergency waivers designed to ensure safe access to care for seniors and other vulnerable populations. As the pandemic raged, Medicare beneficiaries turned to telehealth services to minimize exposure risk and receive medically necessary care in safe and accessible settings. In April 2020, more than two-fifths (43.5%) of Medicare FFS primary care visits were provided through telehealth, and from mid-March through early July of that year, more than 10.1 million beneficiaries accessed telehealth services.
Without further congressional action, however, these emergency flexibilities will expire at the end of the public health emergency, creating chaos for tens of millions of Medicare beneficiaries, including many who have come to rely on telehealth for critically needed care. Our nation’s seniors deserve better. The Telehealth Modernization Act would help to support their needs through necessary updates to coverage policies.
The Telehealth Modernization Act makes permanent two changes:
•Ensures that patients can access telehealth anywhere by permanently removing Medicare’s so-called “geographic and originating site” restrictions, which required both that the patient live in a rural area and use telehealth at a doctor’s office or certain other clinical sites.
•Protects access to telehealth for patients in rural areas.
And gives the U.S. Secretary of Health and Human Services new authority to do these three things:
•Help patients continue to access telehealth from physical therapists, speech language pathologists, and other health care providers.
•Help give Medicare recipients many more telehealth services.
•Help Medicare hospice and home dialysis patients use telehealth to keep receiving necessary care.
Supporting Organizations: ACT | The App Association, Alliance for Aging Research, Alliance for Connected Care, American Academy of Neurology, American Association for the Study of Liver Diseases, American Clinical Neurophysiology Society, American Heart Association, American Medical Association, American Nurses Association, American Telemedicine Association, American Urological Association, College of Healthcare Information Management Executives, Connected Health Initiative, eHealth Initiative, Endocrine Society, Health Innovation Alliance, HIMSS, Infectious Diseases Society of America, Medical University of South Carolina, National Association of ACOs, National Hospice and Palliative Care Organization, National Multiple Sclerosis Society, National Organization for Rare Disorders, Palmetto Care Connections, Personal Connected Health Alliance, Prisma Health, Society of General Internal Medicine, South Carolina Hospital Association
The Public Health Emergency introduced a myriad of changes to federal and state telemedicine and digital health laws and rules. There were expansions to telehealth coverage and reimbursement, suspension of enforcement on HIPAA security for digital health, expedited FDA review processes, DEA exemptions of controlled substance prescribing rules, and state waivers of medical licensure requirements. Nearly all these changes, whether permanent or temporary, were telemedicine-friendly and promoted the use of digital health technology to deliver medical care.
But one change, signed into law in the last days of December 2020, has raised confusion (and eyebrows) in the telemental health provider community. It is a single sentence, contained in Section 123 of the Consolidated Appropriations Act of 2021. It reads:
“Payment may not be made under this paragraph for telehealth services furnished by a physician or practitioner to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder unless such physician or practitioner furnishes an item or service in person, without the use of telehealth …” (emphasis added).
In short, the Act changes the Medicare telehealth coverage statute, expanding Medicare payment beyond substance use disorder treatment (already required under the SUPPORT Act) to more broadly cover treatment of mental health disorders. Most telemedicine industry stakeholders would support expanded Medicare coverage of telehealth-based mental health services. The need for access to mental health care is high, considering the well-documented shortage of mental health practitioners nationwide, particularly in rural areas. However, under this new law, Medicare will cover the telehealth mental health service only if the practitioner has conducted an in-person consult with the patient in the prior six months and subsequently continues to conduct in-person exams (at such a frequency to be determined by HHS). Otherwise, Medicare will not pay for the telehealth service.
Here is the language of Section 123 in its entirety.
SEC. 123. EXPANDING ACCESS TO MENTAL HEALTH SERVICES FURNISHED THROUGH TELEHEALTH.
(a) TREATMENT OF MENTAL HEALTH SERVICES FURNISHED THROUGH TELEHEALTH.—Paragraph (7) of section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended—
(1) by striking ‘‘DISORDER SERVICES FURNISHED THROUGH TELEHEALTH.—The geographic’’ and inserting ‘‘DISORDER SERVICES AND MENTAL HEALTH SERVICES FURNISHED THROUGH TELEHEALTH.—
‘‘(A) IN GENERAL.—The geographic’’;
(2) in subparagraph (A), as added by paragraph (1), by inserting ‘‘or, on or after the first day after the end of the emergency period described in section 1135(g)(1)(B), subject to subparagraph (B), to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder, as determined by the Secretary,’’ after ‘‘as determined by the Secretary,’’; and
(3) by adding at the end the following new subparagraph: ‘
‘(B) REQUIREMENTS FOR MENTAL HEALTH SERVICES FUR- NISHED THROUGH TELEHEALTH.—
“(i) IN GENERAL.—Payment may not be made under this paragraph for telehealth services furnished by a physician or practitioner to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder unless such physician or practitioner furnishes an item or service in person, without the use of telehealth, for which payment is made under this title (or would have been made under this title if such individual were entitled to, or enrolled for, benefits under this title at the time such item or service is furnished)—
“(I) within the 6-month period prior to the first time such physician or practitioner furnishes such a telehealth service to the eligible telehealth individual; and
“(II) during subsequent periods in which such physician or practitioner furnishes such telehealth services to the eligible telehealth individual, at such times as the Secretary determines appropriate.
‘‘(ii) CLARIFICATION.—This subparagraph shall not apply if payment would otherwise be allowed—
‘‘(I) under this paragraph (with respect to telehealth services furnished to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or cooccurring mental health disorder); or
‘‘(II) under this subsection without application of this paragraph.’’.
(b) IMPLEMENTATION.—Notwithstanding any other provision of law, the Secretary may implement the provisions of, or amendments made by, this section by interim final rule, program instruction, or otherwise.
This is not the first time restrictions have been imposed on Medicare reimbursement for telehealth or virtual care services. For example, certain CPT service codes are limited to established patients, select items of durable medical equipment have had a “face-to-face encounter” requirement, and the geographic and originating site restrictions on telehealth have been in place for nearly 20 years. Yet, this law may very well be the first and only instance of a federal statute expressly mandating an in-person exam as a prerequisite for Medicare coverage of a telehealth-based service.
Little legislative history is readily available that reflects Congressional lawmakers discussing the merits of Section 123’s requirement for an in-person exam. To be fair, at 5,593 pages and $2.3 Trillion, this legislation is the longest bill ever passed by Congress and one of the largest spending measures ever enacted. But the in-person exam requirement is at odds with the direction that telehealth policy has moved over the last decade. It disrupts Medicare’s historical approach, which is to defer to state laws on professional practice requirements and clinical standards of care.
State laws vary on their specific requirements and practice standards, but at this point generally allow the creation of valid doctor-patient relationships via telemedicine without an in-person exam, assuming the standard of care is met. Additionally, 43 States now have telehealth coverage laws requiring commercial health plans to cover services delivered via telehealth. Some states, like Massachusetts’ recent telemedicine law, even take extra steps to ensure reimbursement of telehealth-based mental health care, and CMS itself includes new patient evaluation/management (E/M) service codes (e.g., CPT Codes 99201-99205) among the Medicare-covered telehealth services.
Moreover, Section 123’s new prerequisite for an in-person visit applies only to mental health treatment. Medicare beneficiaries seeking medical services via telehealth are not subject to this requirement. It is only those patients seeking treatment of mental health disorders who are required to “mask up” and head to their practitioner for an in-person exam. It prompts consideration as to why mental health care is being held to different payment restrictions than medical care, despite years of efforts on mental health parity and the passage of the Mental Health Parity and Addiction Equity Act.
While expansion of Medicare coverage for telehealth services can increase access to care, particularly as the Public Health Emergency continues, the policy implications of Section 123’s in-person exam requirement may leave patients and practitioners wondering if the Act actually gives as much as it takes.
Angus King (I-Maine), Maggie Hassan (D-N.H.) and Mark Warner (D-Va.) are urging the FCC to administer the Emergency Broadband Benefit Program in a way that helps address the longstanding digital divide.
The senators are encouraging the FCC to design the program in a way that helps to establish a “durable, scalable model for future digital equity efforts,” and lays out specific steps to ensure that all Americans can access this essential 21st century tool.
“As communities across the country continue to grapple with connectivity challenges as a result of the coronavirus pandemic, we have seen unprecedented reliance on telepresence services, including telework, online education, telehealth, and remote support services,” the senators wrote in a letter to the FCC this week. “Unfortunately, the already-existing digital divide has been further exacerbated by these disruptions, which have highlighted and furthered the broadband gap that too many American households still face. While Congress continues to work with the FCC and other Federal agencies on expanding broadband access to unserved and underserved areas through a number of programs, affordability remains a significant barrier to connectivity for far too many Americans. According to Pew Research, approximately half of non-broadband users’ given reason for lack of connectivity is prohibitive cost, and 44 percent of households earning $30,000 or less do not have broadband. With the establishment of the Emergency Broadband Benefit Program, and with proper, forward-looking implementation, we believe we can make a substantial difference in supporting broadband affordability for the most vulnerable Americans.
The letter from King, Hassan and Warner goes on to lay out additional steps that the FCC should take in order to maximize the reach and impact of the EBBP both during this crisis and in the long-term.
The senators highlight the value of collaborating, with state and community partners, urge the commission to set the eligibility criteria as broadly as reasonably possible, and emphasize the importance of supporting newer or smaller broadband services, many of which operate in historically underserved areas.
COLUMBIA, S.C. — Two Pee Dee organizations were awarded in total more than $1 million in USDA grants to develop long-distance solutions to better serve not only rural students but also rural residents.
The grants are part of $42.3 million the U.S. Department of Agriculture is providing to help rural residents gain access to health care and educational opportunities.
Williamsburg County School District will use a $792,441 grant to establish a distance learning system to make dual enrollments available to students. It will also expand science, technology, engineering and mathematics (STEM) initiatives for 3,700 students and provide training for teachers in Greeleyville, Hemingway, Lanes, Kingstree, Salters and Stuckey.
McLeod Health will use a $697,674 grant to provide telehealth services to rural communities in Clarendon, Chesterfield, Marlboro counties as well as lower Florence County.
Telehealth platforms will be installed at several public schools in the area to help students receive primary care visits and prescriptions. In addition, a platform will be placed in primary care offices in Manning and Cheraw to enable pulmonologists to perform remote visits on patients with lung ailments.
Rural areas are seeing higher infection and death rates related to COVID-19 due to several factors, including a much higher percentage of underlying conditions, difficulty accessing medical care, and lack of health insurance. The $42.3 million in awards includes $24 million provided through the CARES Act. In total, these investments will benefit 5 million rural residents.
“The Distance Learning and Telemedicine program helps rural communities use the unique capabilities of telecommunications to connect to each other and to the world, overcoming the effects of remoteness and low population density,” said Marty Bright-Rivera, USDA South Carolina acting state director for rural development. “USDA is committed to working with the local communities to provide services which allows rural America equal access to quality healthcare and education, because we know when we work together, America prospers.”
Investments Will Benefit 5 Million Rural Residents
WASHINGTON, Feb. 25, 2021 – The United States Department of Agriculture (USDA) today announced it is investing $42.3 million to help rural residents gain access to health care and educational opportunities (PDF, 255 KB). Rural areas are seeing higher infection and death rates related to COVID-19 due to several factors, including a much higher percentage of underlying conditions, difficulty accessing medical care, and lack of health insurance. The $42.3 million in awards includes $24 million provided through the CARES Act. In total, these investments will benefit 5 million rural residents.
“The coronavirus pandemic is a national emergency that requires a historic federal response. These investments by the Biden Administration will help millions of people living in rural places access health care and education opportunities that could change and save lives,” said Agriculture Secretary Tom Vilsack. “USDA is helping rural America build back better using technology as a cornerstone to create more equitable communities. With health care and education increasingly moving to online platforms, the time is now to make historic investments in rural America to improve quality of life for decades to come.”
A recent report (PDF, 214 KB) by the Rural Policy Research Institute’s Center for Rural Health Policy Analysis found infection and death rates in rural America due to COVID-19 are 13.4 percent higher than in urban areas. A recent report from USDA’s Economic Research Service, USDA ERS – Rural Residents Appear to be More Vulnerable to Serious Infection or Death From Coronavirus COVID-19, underscored the challenges facing rural Americans amidst the COVID-19 pandemic with even greater detail. Due to a confluence of factors, including higher percentages of underlying conditions, lack of health insurance, and lower access to medical facilities/care than urban counterparts, ERS analysts found rural Americans are suffering more severe illness or death due to COVID-19.
Rural Residents Appear to be More Vulnerable to Serious Infection or Death from Coronavirus COVID-19
Rural Percent
Urban Percent
Underlying health conditions (ages 20 to 84)
23.7
3.0
Older adult population scale
15.9
4.0
Lacking health insurance (ages 25 to 64)
20.2
10.5
Distance to county with an intensive care hospital
11.3
0.3
The table above is from the USDA ERS January 2021 report: Rural Residents Appear to be More Vulnerable to Serious Infection or Death from Coronavirus COVID-19
Background:
USDA is funding 86 projects through the Distance Learning and Telemedicine (DLT) grant program. The program helps rural education and health care entities remotely reach students, patients and outside expertise. These capabilities make world-class education and health care opportunities accessible in rural communities. The ability to use telehealth resources is critical, especially now during a global pandemic.
USDA announced investments today in Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Hawaii, Idaho, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Mississippi, Missouri, Nebraska, New Hampshire, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, American Samoa, Guam, Puerto Rico and the Virgin Islands.
Below are examples of projects announced today:
In Georgia, the Morehouse School of Medicine Inc. will use a $997,194 grant to purchase interactive telecommunications, distance learning and telemedicine equipment. Equipment will be installed in service hubs in two counties in west-central Georgia. It will be used to provide a variety of health care services to residents in underserved rural areas of nine counties across the state. These services include mental health and substance abuse treatment and counseling; clinical services; referrals for specialty care; health education and career development to schools; and chronic disease diagnosis, treatment and management, including COVID-19.
The Fall Mountain Regional School District in New Hampshire is receiving a $995,158 grant. It will provide distance learning services in Cheshire and Sullivan counties. Distance learning will enable schools to share instructional resources, provide cultural literacy and career pathways programs for students, and provide professional development opportunities. The grant will also help the district respond to the COVID-19 pandemic.
Oklahoma’s Okmulgee Public School District is being awarded a $756,760 grant to provide distance learning services in Creek and Okmulgee counties. Schools will expand course offerings and provide professional development opportunities. The schools will use videoconferencing and interactive display panels to expand the curriculum, including Science, Technology, Engineering and Math (STEM) courses. The equipment this grant provides will help schools respond to the COVID-19 pandemic by enabling students to participate in virtual field trips and join classes from home.
In January, President Biden requested all parts of the federal government to contribute resources to contain the coronavirus pandemic. USDA is responding to the President’s call to action. To date, more than 350 USDA personnel have deployed to assist with standing up vaccination sites, for example. In addition to personnel, USDA is offering its facilities, cold chain infrastructure, public health experts, disaster response specialists, and footprint in rural and Tribal communities across the country. USDA’s commitment to control the pandemic extends to our own staff and facilities, with masking and physical distancing requirements across USDA, a commitment to provide PPE to our front-line workers, and working with states to prioritize vaccinations for our workforce. For more information, visit www.usda.gov/coronavirus. USDA also encourages people seeking health insurance to go to HealthCare.gov now through May 15th due to a special enrollment period. If you are recently uninsured due to a job loss or between jobs, find a plan at HealthCare.gov and keep it for as long as you need it.
USDA Rural Development provides loans and grants to help expand economic opportunities and create jobs in rural areas. This assistance supports infrastructure improvements; business development; housing; community facilities such as schools, public safety and health care; and high-speed internet access in rural areas. For more information, visit www.rd.usda.gov.
USDA touches the lives of all Americans each day in so many positive ways. In the Biden-Harris Administration, USDA is transforming America’s food system with a greater focus on more resilient local and regional food production, ensuring access to healthy and nutritious food in all communities, building new markets and streams of income for farmers and producers using climate-smart food and forestry practices, making historic investments in infrastructure and clean energy capabilities in rural America, and committing to equity across the Department by removing systemic barriers and building a workforce more representative of America. To learn more, visit www.usda.gov.
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USDA is an equal opportunity provider, employer, and lender.
By Riley Bean| February 24, 2021 at 11:07 AM EST – Updated February 24 at 5:40 PM
MONCKS CORNER, S.C. (WCSC) – Santee Cooper’s Board of Directors says they approved draft rates and terms that could allow broadband providers to more quickly build out retail service to unserved areas of South Carolina.
The utility provider says this is possible if they let companies accessing Santee Cooper’s 1,200 miles of excess fiber, as well as their nearly statewide transmission infrastructure.
Santee Cooper officials say they will host a virtual public informational session at 2 p.m. March 2.
Organizers say participants can register by emailing [email protected] by 2 p.m. on March 1. Additionally the organizers say they will invite written questions and comments through March 10 at the same email address.
The draft rates and terms will only be finalized and submitted on April 16, after the public comments are received and reviewed.
Santee Cooper is not a provider of broadband, rather, they say they want to allow providers access to their infrastructure so that they can more rapidly roll out service to unserved areas.
Both the TREATS Act and the Telehealth Modernization Act are being re-submitted this week, as telehealth advocates look to set the agenda for post-COVID-19 connected health coverage.
– As federal and state lawmakers look to establish telehealth policy beyond the coronavirus pandemic, much of the conversation will focus on payment parity.
The study, the firm’s fourth, depicts a nation that had rushed to embrace telehealth roughly one year ago to better deal with the COVID-19 crisis, and was aided by federal and state emergency measures that improved access and coverage. Now lawmakers are grappling with the idea of making some or all of those emergency measures permanent to keep the momentum going.
“During the pandemic, health plans overwhelmingly changed their telehealth coverage and payment policies to encourage providers and patients to use virtual care alternatives to in-person treatment,” says Sunny Levine, an associate with the firm. “This was spurred in part by state and federal policy changes, and in part by health plan’s self-initiated decisions. Post-pandemic, health plans will continue to offer coverage of telehealth and virtual care services, although perhaps not as aggressively as currently seen.”
The path seems somewhat less rocky for some emergency measures. Nearly everyone agrees that telemental health should be permanently expanded to take on the growing issues of substance abuse, depression, stress and anxiety, while measures that expand telehealth coverage to clinics, health centers and the patient’s home are seeing widespread support. This also holds true for proposals to expand the types of providers able to use telehealth, such as therapists, social workers and home health workers, and coverage for remote patient monitoring and asynchronous telehealth.
Both Sarah Iacomini, an associate with the firm, and Alexis Bortniker, one of the firm’s partners, say state and federal actions to expand telehealth coverage will affect how private payers plot their strategies.
“Take a clinician attending to a patient with a chronic illness, for example,” says Iacomini. “They meet regularly, so it would be easier for the patient to adhere to a care plan by attending some visits via telehealth instead of only in-person. If that clinician is not guaranteed payment because the patient’s insurer doesn’t cover telehealth – or even if the private payer pays substantially less solely because the visit is virtual – then that clinician is less likely to offer telehealth to their patients.”
“A patient living in a state with coverage and reimbursement parity provisions, however, would not have their care plan compromised, as the law prevents the private payer from choosing to exert that financial pressure on the clinician,” she adds. “By enacting emergency laws, states also indirectly influence private payers because people who become used to telecommunicating with their healthcare providers will, in turn, exert demand on the insurance market to continue offering telehealth benefits even after temporary laws lapse.”
Meanwhile, the jury’s still out on how federal telehealth policy will evolve. The Centers for Medicare & Medicaid Services expanded some coverage in its 2021 Physician Fee Index, but those steps were small, and Congress hasn’t yet made its imprint on the debate with any action on bills that aimed to expand telehealth access.
“As a general matter, private payers followed Medicare’s lead on telehealth reimbursement during the pandemic, expanding access and increasing payment for providers forced to move to a telehealth model overnight,” Bortniker says. “Changes were broad. Decisions were sometimes hastily made in light of the unprecedented nature of the situation. As the months pass, and payers have more time to mine utilization data and assess the impact of the telehealth expansion, we will likely see payers to proceed in their own direction, straying from Medicare requirements where they are not applicable. Payers will develop their own policies and requirements for telehealth in order to manage costs and have better control over utilization, while still meeting network adequacy minimums.”
It could be that state actions help frame the national debate over reimbursement. Some telehealth advocates say payers should reimburse for telehealth services at the same rate as for in-person care, while others feel that payers should negotiate their own rates with providers.
The Foley & Lardner study shows that payment parity did increase during the past two years. In all, 22 states now have laws that specifically address telehealth reimbursement, up from 16 in 2019, and 14 states now mandate true payment parity, up from 10 two years ago.
Jaqueline Acosta, special counsel at the law firm, notes that 40 percent increase in states with parity laws is actually higher right now, because several states have enacted emergency measures for parity that only remain in effect for the duration of the public health emergency.
“While expansion of coverage for telehealth services is definitely positive, I believe states need to continue to shape informed and clear reimbursement policies for telehealth and digital health services,” she says. “This is a trend I hope continues.”
Nathaniel Lacktman, a partner with Foley & Lardner and chair of the firm’s Telemedicine & Digital Health Industry Team, says that issue will likely dominate state telehealth policy debate in the coming year.
“Payment parity laws were created in response to health plans paying for telehealth services at only a fraction of the rate the health plan pays for the identical service when delivered in person,” he says. “This can occur when a state enacts a broad telehealth coverage law, but fails to include any language regarding the reimbursement or payment of telehealth services. These laws are more intrusive into private contracting and opponents contend they can prevent immediate savings from telehealth by reimbursing telehealth-based services at a lower payment amount.”
But Lacktman also notes that states can design payment parity laws that give payers some leverage. In both Georgia and California, lawmakers set the base at equal coverage for both virtual and in-person services, then allowed payers and providers to negotiate alternate payment rates.
“Ideally, payment parity laws should not prevent the parties from negotiating for different reimbursement rates for telehealth vs. in-person services, so long as such negotiations are truly voluntary by the provider and not forced upon them,” he says. “Well-drafted payment parity laws can level the field for providers to enter into meaningful negotiations with health plans as to how telehealth services are covered and paid. Model payment parity laws should not eliminate opportunities for cost savings, and should allow health plans and providers to contract for alternative payment models and compensation methodologies for telehealth services, so long as those negotiations are voluntary.”
Obesity isn’t just a sensitive health issue — it’s dangerous and potentially deadly. Providers and payers are now using connected health tools to drive that point and enhance treatment.
America has a weight problem, with very serious consequences. And telehealth could be the answer to how people — and their care providers — come to grips with girth.
According to the Centers for Disease Control and Prevention, some 42 percent of the American population is classified as obese, up from 31 percent just two decades ago, while severe obesity has nearly doubled, from 4.7 percent to 9.2 percent. And those numbers are rising, fueled by a sedentary lifestyle, unhealthy foods, and a lack of understanding how serious it can be.
It’s more than just an issue of eating too much and exercising too little. Obesity-related conditions include heart disease, type 2 diabetes, stroke, and certain types of cancer. Extra weight can exacerbate many other chronic conditions, and it’s a gateway to reduced quality of life and preventable, premature death.
It’s also a sensitive issue: People don’t like to talk about their weight or being told to lose weight. And that’s where telehealth comes into play.
While healthcare providers can use connected health channels to have discreet, personal conversations with patients about their weight, they can also use these platforms and tools to offer education and resources, on-demand treatment, and support for everything from lifestyle choices to addiction triggers, even remote patient monitoring to keep patients on a care plan.
“Everything we do from a treatment standpoint can be done virtually,” says Angela Fitch, MD, FACP, FOMA, associate director of the Massachusetts General Hospital Weight Center and a faculty member at Harvard Medical School. “From medication [management] to counseling to treatment, we can do a lot more and have a bigger impact” via telehealth than in-person.
Using Telehealth to Tackle a Sensitive Topic
Obesity is often included in the category of health concerns that strike a sensitive chord with patients, like sexual health and diseases, gender-related concerns and issues with appearance and mental health. The emergence of direct-to-consumer telehealth platforms — think Ro, Nurx, Hims and Hers and even Planned Parenthood — has given consumers a discreet channel to address these concerns.
But for most people, the first contact is the primary care provider.
With the idea that many people aren’t comfortable talking about obesity unless they’re alone with a doctor, and they’re reluctant or embarrassed to seek help, primary care providers and specialists have taken to using telehealth to have that conversation.
Fitch says the platform offers an ideal opportunity to mix behavioral and clinical care, two critical elements of obesity treatment.
Getting patients to open up about their weight issue may be a good start, she says, “but people need more than to just talk. They need help. They need tools.”
She says many people still don’t connect weight with serious health outcomes. They’ll spend lots of money on diet aids and supplements, and talk about exercise and healthy activities, but to them it’s more about better living than living better.
“You have to live differently within the environment,” she says. “And for that you need coaching. Even Michael Phelps has a [swimming] coach, and he knows how to swim.”
That coaching works best when it’s tied into telehealth, giving both patient and provider the opportunity to connect on their own terms. And when it’s tied to clinical treatment, it carries the added weight of being prescriptive. Patients can connect with their care providers as needed, on a daily or weekly basis, and talk about both motivations and care management.
“That’s where we need to go next,” Fitch says, describing care routines that mix coaching and support with medication management, remote monitoring, and access to specialists when needed. “You need accountability for this to work, and you need structure.”
Looking ahead, Fitch would like to see clinical weight management programs that allow care providers to pull in data from wearable mHealth devices, such as fitness bands, smartwatches, and sensor-embedded garments. There are also a lot of possibilities with smart objects in the home that would allow providers to offer advice, resources, even a gentle nudge in the right direction as a patient goes through his or her daily routines.
“There’s no reason why you shouldn’t be able to get on your scale each morning and I can see that data,” she points out.
Making Obesity Treatment a Clinical Concern
While obesity is measured in terms of body mass index (BMI), starting at 30.0 (40.0 and above is termed class 3 obesity, or morbid, severe or extreme), it can also be measured in terms of cost. In 2008, the American healthcare ecosystem spent almost $150 billion on treatment of health issues caused by obesity, while someone dealing with obesity sees roughly $1,500 more per year in medical costs.
And that’s making the healthcare industry sit up and take notice.
Obesity treatment is “an emerging service,” says Louis Aronne, MD, FACP, Intellihealth’s Chief Medical Officer and medical director of the Comprehensive Weight Control Center at Weill Cornell.
Up until the past few years, he says, it was regarded as a behavioral health issue, rather than a clinical one. But with studies proving the negative health effects of weight gain — particularly in chronic conditions — care providers and some payers are now taking it seriously.
“The problem has been that providers don’t know how to treat it,” Aronne says. “It has taken a long time for obesity to be treated as a disease, and now that it is, [providers] need the resources to be able to treat it.”
Aronne, who launched the American Board of Obesity Medicine and was instrumental in getting the healthcare industry to recognize obesity as a medical issue, sees telehealth and mHealth as integral parts of a treatment program, one that also mixes in behavioral health and integrates with specialist care (cardiology, gastroenterology, endocrinology) when needed.
He says studies have shown that one-third of those in obesity treatment programs that use telehealth have lost at least 5 percent of their body weight, Over a three-year time span, that can amount to more than $700 in reduced healthcare costs, not to mention better health.
“That’s critical,” he says, adding that continued telehealth and mHealth integration can bump the percentage of people losing weight up to 70 percent as both doctors and patients become more comfortable with virtual care. “Telehealth really is the way to get more people involved in improving their health.”
Aronne is in favor of a hybrid approach that combines telehealth and in-person care. While seeing a patient virtually can help providers pick up on aspects of home life that might affect treatment, he says, providers also need to see patients in person, where they can pick up on habits and emotions that might not translate in a virtual visit.
“We need to build this into an evolving platform,” he says.
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Connected Health Tools for Obesity Treatment
While care providers can use connected health to break the ice and talk to reluctant patients about obesity, telehealth, and remote patient monitoring platforms, wearable mHealth devices and apps serve a much larger role in the treatment space. They give providers the opportunity to connect with patients on a regular basis, offering support and resources for weight control, including nutrition and exercise tips, monitoring for addictive behaviors, and on-demand access to peer support.
The Obesity Medicine Association (OMA), a national organization of healthcare providers focused on improving the lives of patients affected by obesity, has also been working to include telehealth in its practice guidelines.
In January 2021, OMA updated its OMA Obesity Algorithm to include practice guidelines for using telehealth. Called ADAPT, it creates a pathway for virtual and telephonic treatments that focuses on assessment, diagnosis, advice/education, prognosis, and treatment.
“With COVID, and even without COVID, many patients are less inclined to seek medical care (for obesity care) if it means meeting with a healthcare provider,” says Harold Bays, MD, a trustee and chief science officer of the OMA and medical director and president of the Louisville Metabolic and Atherosclerosis Research Center. “Telehealth provides a much more convenient and accessible option.”
Bays says the pandemic “has dramatically changed how providers are using telehealth to treat obesity.”
Aside from new medications and clinical measures like surgery, providers are being encouraged to use telehealth and mHealth apps that improve care management. These tools allow for more interventions and the ability to tailor a program to a patient’s specific needs, through coaching and guidance on diet, exercise, and behavioral health.
The importance of virtual guidance is that it can be accessed when the patient needs it most — at home or the office, or when grocery shopping, out to dinner, at the gym, on vacation, or any other place where a little advice or support is needed.
mHealth tools, meanwhile, can arm the care provider with even more data to influence treatment. By monitoring a patient’s weight and comparing that with other metrics, a care provider can show how weight gain affects the heart, pancreas, lungs and other organs, as well as how exercise and diet might affect those metrics in a positive way.
As Fitch mentioned, the future of obesity prevention and treatment may rest in the smart home concept, with sensors and smart devices programmed to help a consumer make informed choices on diet and exercise and alert caregivers if something is out of the ordinary.
Tackling Type 2 Diabetes Through Virtual Weight Control Programs
While obesity has a profound impact on a number of chronic diseases, it’s one of the root causes of type 2 diabetes. With that in mind, providers and payers across the country are integrating telehealth into diabetes prevention programs to help patients manage their weight and reduce the risk of developing diabetes.
This past January, Humana’s Medicaid program in Kentucky, called Healthy Horizons, launched a virtual diabetes management program with Vida Health. The program is aimed at improving access to care in a state where almost 14 percent of the adult population is living with diabetes – well above the national average of 11 percent – and where roughly two-thirds are overweight.
“Diabetes is a complex disease that requires management of current problems as well as of preventing future complications,” says Jeb Duke, executive director of Kentucky Medicaid and a regional vice president at Humana. “Interacting with the virtual team allows for reminders of both treatment of current issues and prevention care. It also allows for positive reinforcement and praise for successes that our members achieve.”
Duke says a virtual platform allows care teams to expand their reach beyond the clinic or classroom.
“Although it does not replace the need for in-person medical visits, it is a great adjunct that decreases barriers to access for members that frequently struggle with transportation issues,” he says. “It results in increased convenience for our members in accessing the platform to connect with virtual coaches and therapists as well as learning modules to allow for a better understanding of their medical condition.”
Developed by the National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), the diabetes prevention program (DPP) focuses on in-person classes and one-on-one coaching. Based on that model, which is administered by the Centers for Disease Control and Prevention, CMS created the National Diabetes Prevention Program for Medicare beneficiaries and launched that program in 2018.
Telehealth advocates hope CMS will make the coverage permanent.
“It’s no secret that diabetes is a disease that has disproportionately affected minority communities across the country,” a group of Senators said when introducing a bill in September 2020 calling for permanent coverage. “To ensure that all individuals have the tools needed to combat this preventable disease, the Prevent Diabetes Act would help expand access to virtual classes under the existing Medicare Diabetes Prevention Program. This commonsense and cost-saving expansion will ensure that more Americans at risk of developing diabetes who are living in either rural or medically underserved communities, can participate in this critical program that has been proven to delay the full onset of this preventable disease.”
Should that happen, Medicare coverage will open up virtual channels for a significant population — one that shows high rates of obesity and a propensity for developing chronic diseases like type 2 diabetes. It would also throw significant support behind virtual obesity treatment programs that target any number of conditions or populations.
Getting Everyone on Board With Telehealth
While providers are seeing the clinical effects of obesity, payers and employers have been reluctant to make that connection.
“The thing that’s been stopping them is they’re worried that they’re going to be saddled with enormous costs for care,” Aronne says.
Fitch says roughly 30 percent to 40 percent of payers are now covering obesity treatment, convinced that clinical treatments can improve outcomes over the long run and reduce chronic diseases and care management costs. But like CMS, they’re still skeptical of virtual care.
“Payer support is going to be very important,” she says.
This doesn’t mean creating a few extra CPT codes, either. Fitch notes that billing and coding routines are time-consuming and, in some cases, more trouble than they’re worth, prompting providers to skip the process and forego the reimbursements. She’s hoping that obesity treatment will be incorporated into existing care pathways, so that it’s part of the standard of care instead of a new service.
Both she and Aronne see the COVID-19 crisis as helping to prove the value of telehealth delivered to the patient’s home — which, in turn, will give providers more freedom to create care management programs that include obesity prevention and treatment.
“This needs to be part of the new normal,” Aronne says. “Everyone should be using these strategies.”
Palmetto Care Connections (PCC) is the telehealth network for South Carolina that offers telehealth support services to rural and underserved health care providers.
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