Ramona Midkiff

Congress and CMS are being inundated with requests to make permanent telehealth guidelines enacted to expand coverage during the coronavirus pandemic. Here’s a rundown of what they’re requesting.

June 15, 2020 – The ongoing coronavirus pandemic has pushed telehealth and mHealth to center stage as healthcare providers of all sizes look to provide care on virtual platforms. But the emergency – and the legislative and policy measures enacted to deal with it – won’t last forever.

So what happens to telehealth then? What does this impending “new normal” hold for connected health?

(For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.)

With telehealth adoption at record levels and both providers and patients calling for continued coverage, federal and state governments are under pressure to make those emergency measures permanent. Congress is under particular pressure to pass laws expanding telehealth coverage, and the Centers for Medicare & Medicaid Services has signaled a willingness to review and likely revise its guidelines for Medicare and Medicaid coverage.

This Wednesday, the Senate Committee on Health, Education, Labor and Pensions (HELP) is conducting a hearing on telehealth lessons learned during the pandemic. The committee is scheduled to hear from Joseph Kvedar, president of the American Telemedicine Association (ATA) and a digital health expert with Boston’s Partners HealthCare Network; Karen S. Rheuban, director of the Karen S. Rheuban Center for Telehealth at the University of Virginia and a past ATA president; Andrea Willis, senior vice president and chief medical officer with BlueCross BlueShield of Tennessee, one of the first payers in the nation to make telehealth coverage permanent; and Sanjeev Arora, founder and director of the Project ECHO Institute at the University of New Mexico Health Sciences Center.

READ MORE: COVID-19 Gives Providers a Blueprint for New Telehealth Strategies

In addition, 29 Senators sent a letter to Congressional leadership this week asking that telehealth provisions in the CONNECT for Health Act and included in recent COVID-19 emergency measures be made permanent.

“Americans have benefited significantly from this expansion of telehealth and have come to rely on its availability,” the letter, dated June 15, reads. “Congress should expand access to telehealth services on a permanent basis so that telehealth remains an option for all Medicare beneficiaries both now and after the pandemic. Doing so would assure patients that their care will not be interrupted when the pandemic ends. It would also provide certainty to health care providers that the costs to prepare for and use telehealth would be a sound long-term investment.”

Here’s what a few of the experts and advocates are saying about specific connected health measures that should be extended.

“Before the pandemic, Medicare fee-for-service coverage of telehealth services was extremely restrictive, with limitations for rural locations, originating sites, eligible practitioners and services, and qualifying technology,” says Thomas J. Ferrante, senior counsel at the Foley & Lardner law firm. “The CARES Act allowed CMS to temporarily remove these requirements under broad waivers.”

Ferrante says both CMS and Congress will need to act.

READ MORE: Telehealth Will Continue to Grow After Coronavirus Pandemic

“For example, removing the requirement that the patient be located in a qualifying originating site will require Congress to pass legislation amending the current statutory requirement,” he says. “Conversely, the amount of payment for telehealth services, and the specific CPT codes that will be paid by Medicare, can be adjusted by CMS without the Legislature’s approval.”

Ferrante notes that telehealth coverage has long faced an uphill battle, particularly with Medicare, because there hasn’t been enough evidence to prove the utilization improves clinical outcomes and drives down costs. Advocates are hoping to see that proof in how telehealth has been used during the pandemic, and US Rep. Robin Kelly has sponsored a bill calling for such a study – but that study wouldn’t be due back to Congress until the end of 2024, likely well after the bloom has faded and the momentum has waned.

“Notwithstanding, such opponents’ arguments, telehealth has become popular enough, and enough information may be gleaned from this pandemic experiment to garner the requisite bipartisan support,” Ferrante says. “Healthcare industry stakeholders should write and lobby members of Congress to make some telehealth waivers permanent through the next round of major coronavirus legislation under consideration. Similarly, stakeholders should provide their comments during the next release of proposed rulemaking by CMS.”

Nadia de la Houssaye, a partner with the Jones Walker law firm, says Congressional action on CMS’ telehealth coverage is “long overdue and critically important.” In particular, she’s looking at CMS guidelines that limit telehealth to rural areas and don’t allow coverage for telehealth in clinics, health centers or the patient’s home.

“Telehealth reimbursement should not be limited to a patient’s geographical location,” she notes. “CMS’ prompt action to lift originating site barriers played a significant role in provider adoption and usage of telehealth in the midst of COVID-19. …. All Medicare beneficiaries should have equal access to covered healthcare benefits, regardless of where and how care is delivered. Permanent removal of CMS’ pre-pandemic geographic and reimbursement barriers will ensure better and more affordable care to our nation’s most vulnerable population – the elderly and disabled.”

READ MORE: New Bill Aims to Make Telehealth Coverage Permanent for FQHCs, RHCs

Four other topics are on de la Houssaye’s radar as well:

State licensure barriers: “State licensure laws have long been one of the greatest barriers to interstate telehealth expansion,” she says. “Not only is the licensure process expensive, timely and onerous, (but) regulations and policies vary across state lines. Post-COVID-19, re-evaluation at the state and federal level must occur to eliminate state licensure barriers.”

Options include have a state waive its licensure requirement if a provider has a license in another state, creating cross-border licensure waivers with neighboring and/or rural states or making the Interstate Medical Licensure Compact nation-wide—though joining the compact expedites licensure but doesn’t eliminate all barriers.

At the federal level, de la Houssaye suggests legislation designating the provider’s location as the location in which care takes place for the purposes of licensure and payment. “Though states will likely resist such federal legislation, state licensing boards will nevertheless maintain control over issuing provider licenses located in the state, while allowing providers to treat patients remotely in other states,” she says. “Additionally, Congress could re-visit the TELE-MED Act of 2015, which would permit Medicare providers who are licensed in one state to provide telehealth services to Medicare patients across state lines and without the need for additional state licenses. Though removal of state licensure barriers will not happen overnight, it is essential to the future of telehealth.”

Broadband internet access: “Without fast and reliable access to high-speed broadband, telehealth is limited,” de la Houssaye points out. “To deliver on telehealth’s potential, adequate bandwidth must be available throughout the continuum of care. Congress and the FCC have accelerated efforts to address this infrastructure barrier through significant grant funding initiatives, including the COVID-19 Telehealth Program and the three-year Connected Care Pilot program. This federal funding not only recognizes the essential role telehealth will play post-pandemic, but more importantly the critical need for an infrastructure that will support its use.”

HIPAA, data security and privacy: “To protect patient privacy, it is important that HIPAA and data security measures return to post-pandemic levels and that emerging new technology platforms abide by these established regulations and standards,” de la Houssaye says. “Not only must platforms contain the requisite security measures, providers must be reminded that it is unacceptable to engage in a telehealth encounters in public or with family members in the same room.”

De la Houssaye has the anecdotes to back up those concerns. She says she’s seen a physician conducting a virtual visit while shopping at Target, and talked on the phone with a woman who had to speak softly to avoid disrupting her physician-husband’s telemedicine session in the living room.

Private payer reimbursement: de la Houssaye notes that states have enacted vastly different guidelines for private payer coverage. “State and federal action is needed to incentivize providers to continue telehealth usage post-pandemic,” she says. “While the federal government can promote telehealth by setting minimum coverage and reimbursement standards for Medicaid, state insurance regulators, Medicaid agencies and medical boards can all change rules for practice, coverage and reimbursement to promote greater use of telehealth services for those not insured through federal programs.”

Additionally, post-COVID-19 is a good time to evaluate alternative payment models that reward value in the remote delivery of services, rather than traditional fixed fee reimbursement,” she concluded.

Carrie Nixon, a healthcare innovation attorney and managing partner of the Nixon Law Group, sees two potential courses of action:

Incentivize provider adoption and implementation of telehealth and remote patient monitoring programs through a two-pronged approach. First, she says, Congress should pass legislation establishing a pool of funds available to providers across the entire spectrum of care, public and private, for exactly this purpose (similar to the HITECH Act). Second, CMS should use the carrot-and-stick approach under MACRA’s Quality Payment Program, making implementation of a virtual care program a high-weighted “Improvement Activity” metric for providers in the MIPS track, and a requirement for all participants in the Advanced Alternative Payment Model track.

Finalize proposed changes to the fraud and abuse landscape to allow telehealth, RPM and other digital health companies to enter into previously prohibited business arrangements with providers to facilitate the transition to a true value/outcomes based model of delivery and reimbursement. For example, Nixon says, the proposed Patient Engagement and Support safe harbor should be finalized, allowing RPM companies to provide incentives to patients for adhering to their RPM program by taking a certain number of readings per month. And the proposed Care Coordination Arrangements safe harbor should be finalized to allow “in-kind remuneration” like sharing of staff between a provider and a vendor for RPM monitoring, allowing a vendor to provide devices to be used in conjunction with its telehealth platform for free to providers and others.

Also weighing in are government agencies like the Federal Trade Commission, which sent a letter in May to CMS listing six telehealth directives that should be extended beyond the pandemic.

“Telehealth can potentially increase the supply of accessible practitioners and thereby enhance price and non-price competition, reduce transportation expenditures, and improve access to and choice of quality care,” the letter stated. “Many experts consider reducing restrictions on Medicare reimbursement of telehealth services especially important for fulfilling telehealth’s potential, not only because Medicare places substantial limitations on using telehealth services, but also because Medicare influences the reimbursement policies of state Medicaid programs and private payers.”

In addition, the ATA sent a letter to Congressional leadership in May outlining funding and policy changes that should be part of the next coronavirus relief package, with the goal of extending telehealth freedoms long past the current crisis.

The ATA’s letter listed nine recommendations:

1. Expand the Federal Communications Commission’s $200 million COVID-19 Telehealth Program to include for-profit hospitals and health systems and others not included in the pool, and add another $300 million to the pot.
2. Expand the FCC’s Health Care Connect Fund Program to include public, non-profit entities.
3. Increase funding for the Health and Human Services Department’s Public Health and Social Services Emergency Fund.
4. Provide a payroll tax credit for COVID-19 hospital facility expenditures, which often include the purchase of telemedicine equipment and additional telehealth training.
5. Amend Medicare Part B cost sharing to increase flexibility for telehealth use.
6. Have HHS forge an agreement with at least one eligible organization to collect, analyze and report on telehealth, digital health and remote patient monitoring metrics. That group should partner with stakeholders to analyze utilization, cost, access, experience data and identified structural and policy barriers to care.
7. Incorporate telehealth and RPM platforms into the National Health Security Strategy.
8. Prioritize telehealth policy and elevate the Office for the Advancement of Telehealth, which is currently categorized under the Office of Rural Health Policy in the Health Resources and Services Administration.
9. Address outdated 1834(m) restrictions on telehealth, perhaps by enacting the CONNECT Act for Health (S.2741 and HR.4932).

A bill introduced this week in the House would ensure Medicare coverage for telehealth services provided by FQHCs and RHCs and eliminate originating site facility and location requirements for distant site telehealth services.

June 12, 2020 – A bill introduced in Congress this week aims to improve telehealth coverage for federally qualified health centers (FQHCs) and rural health clinics (RHCs).

Introduced by US Reps. Glenn Thompson (R-PA) and George Butterfield (D-NC), the Helping to Ensure Access to Local TeleHealth (HEALTH) Act of 2020 would, if approved, mandate Medicare coverage for telehealth services at these clinics and remove originating site facility and location requirements for distant site telehealth services delivered by them.

The bill would make permanent connected health coverage included in the CARES Act, which only lasts as long as the COVID-19 emergency, and bring into the spotlight one of the most troubling barriers to widespread telehealth adoption.

As defined by the Centers for Medicare & Medicaid Services, there are roughly 1,400 FQHCs and another 4,300 RHCs in the US, many of them serving predominantly underserved populations and communities. Because they’re haven’t been considered a distant site for telehealth by CMS, opportunities for reimbursement are few and far between, and many rely on grants and donations to offer telehealth services.

With the coronavirus pandemic sharply curtailing in-person care and putting both patients and providers at risk of catching the virus, many clinics have turned to telehealth and mHealth to keep the virtual doors open.

But the telehealth freedoms enabled by the CARES Act last only as long as the emergency. In addition, many experts note that the nation’s current economic troubles and soaring unemployment rate will leave millions without health insurance and push them toward these clinics for care.

Some states – notably Colorado and California – made moves prior to the pandemic to extend telehealth coverage for FQHCs and RHCs. In addition, the Creating Opportunities for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019, introduced for a third time by a large group of Senators in October 2019, proposes to remove geographic restrictions on originating sites for FQHCs and other locations and allow them to qualify as distant sites for telehealth reimbursement.

“The HEALTH Act recognizes the new normal that community health centers and our patients are living in,” Chris Shank, CEO and president of the North Carolina Community Health center Association, said in a press release issued by Thompson and Butterfield. “The pandemic has led community health centers nationwide to adopt innovations like telehealth in order to protect the safety of patients and the medically underserved communities we serve. Through the temporary telehealth changes thus far, community health center patients have been able to access primary care and behavioral health services while physically distancing to limit spread of coronavirus.”

“Patients and providers alike will benefit from permanent telehealth access even once the virus is under control,” he added. “Allowing patients to connect virtually to their health care provider removes significant barriers like transportation, which disproportionately affects patients with lower incomes and those living in rural communities. The HEALTH Act will reduce longstanding barriers to health care access by reducing red tape and providing sustainable reimbursement for telehealth services provided by community health centers.”

June 04, 2020 – June 04, 2020 – If you asked her in January, Ellie Zuehlke, director of Community Benefit and Engagement at Allina Health, would have said the health system would fully implement its virtual strategy, including digitizing its social determinants of health screening and referral, in about five years. She couldn’t have imagined that just a few months later the health system would have pivoted to digital in less than a week.

“In March, our world flipped upside down and we in Minnesota basically shut our clinic,” Zuehlke said to PatientEngagementHIT. “People joke about it but it’s really true. We implemented our five-year virtual strategy in five days.”

At break-neck speed, Zuehlke and partners in the health technology and accountable communities departments revamped technology from NowPow. This tool allows providers to assess a digital social determinants of health screener and provide virtual links to community-based services that can meet the needs detected in the screener. The technology also enables virtual connections between the highest-risk patients and healthcare navigators.

But before that, this was largely a paper-based system, Zuehlke described.

“From our primary care to outpatient mental health to mom and baby and then in the emergency room of three of our hospitals, our workflow was very much a paper-based process,” she said. “A patient would come in, and when they were checking in at the front desk there would be a pop-up in our Epic EMR that would trigger the front desk worker to give the patient a paper-based screening.”

READ MORE: Key Strategies for Remote Chronic Disease Management

Once the patient completed the screening, a care team member — usually a medical assistant — would transcribe the form into the health record. Integration between the EHR and the SDOH software would produce a tailored list of resources. Earlier this year, Allina began work to digitize a referral tracking process, too.

But as Zuehlke noted, COVID-19 took over the healthcare industry in March, pushing many organizations like Allina, to close its primary care and other non-emergent healthcare facilities. And like many others in the industry, Allina filled care access gaps using telehealth to help maintain care management for patients.

But that didn’t really jibe with their paper-based system for SDOH screening.

“We saw 85 percent reduction in our visit volumes, and those office visits really were the driver for patients to screen for social needs,” said Dan Behrens, MHA, manager of Accountable Health Communities at Allina Health.

Of course, there was a way the Allina team could still lean on paper-based SDOH screening. The patient could still complete a form and send it to her telehealth provider, and then the provider could transcribe that into the EHR. But this is time- and labor-intensive and doesn’t deliver on the quick, convenient, and cost-effective care that telehealth promises.

READ MORE: How AdventHealth Saved Patient Experience During COVID-19

“We started looking at how we could try to build the same screening for people,” Behrens said. “We built the screen into our patient portal. That allows us to basically send this screener out through the patient portal five days prior to the visit so the patient had ample time to document and review the screening tool. Then all of those answers and responses would go directly back into our EMR.”

The health system has also digitized how it tracks these referrals. Referral tracking is an important aspect of SDOH interventions because it allows medical providers to know if patients have connected to the services that they need. Additionally, it helps providers know whether those interventions worked to improve health.

Allina is able to track referrals with any social services that have also jumped on board to digital SDOH tracking and referral. In other words, if a social service has also integrated with NowPow, Allina can conduct digital coordination and tracking with it.

“Let’s say we had a food need in the north metro, our navigator would hand that patient over to the organization directly,” Behrens offered as an example. “That organization would do outreach to that patient for that need. All the community partner is doing around the resolution of those needs is documented in the tool, which links back through to our EMR where our navigators can see the outcome of that intervention.”

If the patient hasn’t accessed the social service or is facing access barriers, the patient navigator can link back with the patient to overcome any challenges.

READ MORE: How Will COVID-19 Change Patient Experience, Healthcare Delivery?

Of course, this system isn’t flawless — at the time of publication, Allina has only been on the technology for a few days. That newness compounds with the newness of virtual visits and telehealth, which Zuehlke said can be stressful for providers and patients.

“What is a defining factor — which relates to the implementing a five-year virtual plan in five days thing — is the amount of change,” she said. “It makes it a little bit harder to really understand which of the numerous issues we are facing.”

This is putting a strain on how Allina can assess the success of this program, Zuehlke said. Virtual visits are new for many patients. This SDOH screening technology is new for a lot of patients. And, as COVID-19 has pushed social needs and the importance of community health to the forefront, these evolving relationships with community figures are new for patients.

According to Behrens, this is exactly the area he and his team plan to focus on as they roll out the technology and work to refine the system. The digital program must supplement, not detract from, the face-to-face interactions that have long defined the basis of community-based health and SDOH screening and intervention.

When front desk staffers issue an SDOH screening to a patient, they have the opportunity to explain why the clinic is collecting this information and how providers can use it to improve patient’s health and wellbeing. This practice is essential for building patient trust, which in turn is key for patients disclosing their greatest social and personal needs.

“We’re going to keep a close eye on kind of the response rate that we’re seeing from patients,” he concluded. “Our concern is if they’re feeling that this is an appropriate and comfortable means for them to fill out our screening tool and express needs. We’re keeping an eye on what the completion rate looks like in comparison to what had been our baseline in the offices.”

June 03, 2020 – Community health centers will need a good grasp of telehealth to survive both the coronavirus pandemic and what lies beyond.

That’s the take-away from a new article in Health Affairs, which notes the lack of telehealth adoption prior to COVID-19 and outlines three steps that should be taken to bring CHCs, which serve more than 28 million underserved Americans, up to speed with connected health.

(For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.)

That strategy may be crucial. While federal and state governments have taken steps to boost telehealth adoption during the ongoing pandemic, CHCs, federally qualified health centers and rural health centers have in many cases struggled to use the technology because they hadn’t laid the groundwork prior to the pandemic. Meanwhile, with the nation in the midst of an economic slump and hundreds of thousands without jobs, these health centers will likely see a surge in traffic as more and more people lose their health insurance.

The Health Affairs article, written by June Ho-Kim of Brigham and Women’s Hospital (and a primary care physician at Upham’s Corner Health Center, a FQHC) and Eesha Desai and Megan Cole of the Boston University School of Public Health, points out that only 38 percent of the nation’s 1,330 CHCs were using telehealth in 2016, and two years later that number had only jumped to 44 percent.

READ MORE: New Bill Aims to Give FQHCs, RHCs Relief From Telehealth Paperwork

Of the 56 percent not using telehealth in 2018, only one in every five was giving it any thought. And of the 44 percent using telehealth at that time, roughly 70 percent were providing telemental health services and 47 percent were using it for specialist consults – and only 30 percent were using telehealth for primary care and 21 percent were offering chronic care management services.

Furthermore, CHCs faced significant barriers to adoption telehealth. The top three were lack of reimbursement – prior to COVID-19, Medicare didn’t reimburse for telehealth services at these centers and didn’t recognize them as a distant site for telehealth delivery – lack of resources and lack of training. In rural areas, meanwhile, almost 20 percent didn’t have the broadband connectivity to support telemedicine technology.

The COVID-19 emergency changed that dynamic. With the pandemic reducing in-person care and putting the onus on remote care, CHCs saw their in-person visits plunge and were forced to lay off staff, reduce hours or even close. Federal and state governments responded with a barrage of emergency measures aimed at reducing the barriers to telehealth and boosting reimbursement.

“While an important first step, policy makers cannot simply infuse more funding to CHCs and expect them to withstand the challenges of the COVID-19 era,” the article points out.

It offers three “targeted strategies” for improved telehealth adoption:

1. Mandate payment parity for all telehealth services, not only during COVID-19 but beyond.

READ MORE: Coronavirus Grant Gives Massachusetts FQHCs a Chance to Embrace Telehealth

“Without commensurate reimbursement for telehealth, CHCs cannot maintain patient volume or make the long-term investments necessary to remain financially viable,” the article states. “A ‘ of paying CHCs a fixed payment per patient per month would give practices flexibility in how and where to treat the patient, although this may be politically and practically challenging. Meanwhile, payment parity has already been implemented and could simply be permanently codified into existing reimbursement schemes, giving providers the option to select the best mode of treatment without making financial trade-offs.”

2. Provide funding and guidance for telehealth adoption.

This includes hardware and software, broadband access and training, and ancillary systems to handle traffic on different channels, such as phone and video.

“Adding robust protocols and systems will allow for the successful implementation and scaling of telehealth,” the article states.

3. Provide support so that CHCs can reach vulnerable, underserved populations.

This would include funding for translation services and support for patients not familiar with the technology. Payers, meanwhile, should provide support for patient care navigators and waive any requirements that place geographic or original site restrictions on telehealth and that mandate audio-visual platforms.

Finally, local governments should offer mHealth devices to underserved populations and create internet hotspots and charging stations to improve access. Insurers could support these efforts with reimbursements through the Federal Communications Commission’s Lifeline program.

READ MORE: CMS Clarifies New Telehealth Services and Coverage for FQHCs, RHCs

“COVID-19 may pose long-lasting damaging effects on CHCs and the patient populations that they serve,” Kim, Desai and Cole write. “Nonspecific federal and state funding will allow CHCs to survive; however, deliberate action is needed to enhance telehealth capacities and ensure long-term resilience.”

“By reorienting the goals for implementing telehealth, policy makers, payers, and providers can empower health centers to thrive into the future and meet the nation’s underserved patients where they are, even during the pandemic,” they conclude. “In the long run, telehealth can increase access and equity – but only if the right investments are made now to fill the gaps laid bare by COVID-19.”