• In The Trenches

    Avoiding a Telehealth Cliff

    You can tell it’s August because Congress is slipping out for a long, late-summer recess. A number of representatives and senators are headed home to districts struggling against the COVID-19 delta variant, so let me shout some timely encouragement after them by repeating a message the Academy delivered to lawmakers in two letters last week: telehealth, telehealth, telehealth!

    cell phone tower in field

    Our actual correspondence wasn’t quite that exclamatory but was no less urgent: The rapid and welcome progress made on the virtual-care front the past year and a half — a positive byproduct of the public health emergency — is already in jeopardy, despite basic remedies that are within reach.

    For one thing, clinicians and patients alike have not benefited equally from telehealth’s rapid expansion. Without sustained investment and long-term policy shaped on vigorous data collection, telehealth could end up exacerbating health disparities.

    That’s why the AAFP sent a letter July 28 to Rep. Robin Kelly, D-Ill., expressing support of her Evaluating Disparities and Outcomes in Telehealth Act. The bill directs HHS to further study telehealth use in Medicare and Medicaid during the PHE.

    Calls for study can sound vague, especially when plenty of research is already on the table. So it’s important to note that we used this letter to strongly recommend analyzing volume, patterns and patient outcomes for visits provided by a patient’s usual source of care versus one-off visits provided by a clinician with whom the patient has no relationship. As I’ve told you before, the Academy is adamantly against organizing telehealth policy around outsourced retail services; such a design would only undermine the medical home and fracture relationships and care. Or, to quote our letter to Kelly with added emphasis, “Telehealth technologies can enhance patient-physician collaborations, increase access to care, improve health outcomes by enabling timely care interventions and decrease costs when utilized as a component of, and coordinated with, longitudinal care as well as an existing physician-patient relationship.

    That aside, we like that the EDOT Act calls for an analysis of utilization and patient outcomes broken down by race and ethnicity, geographic region, and income level, as the Academy has loudly advocated. And it directs that data on telehealth use be broken down by service modality (i.e., audio-video or audio-only) and type of care (primary care, mental health, subspecialty, etc.) — invaluable information to CMS and state Medicaid agencies as they weigh whether and how to continue covering different services beyond the pandemic.

    And make no mistake, CMS and state Medicaid agencies need to make coverage of audio-only evaluation and management services permanent. Cementing that coverage is vital for ensuring equitable access to virtual primary care for patients who lack broadband access or are uncomfortable with video visits.

    Audio-only reimbursement also was among the priorities listed in a July 26 letter to congressional leaders — signed by the AAFP alongside some 400 other health care, employer, consumer and technology organizations — urging them to steer clear of an impending telehealth cliff.

    “Telehealth is not a COVID-19 novelty, and the regulatory flexibilities granted by Congress must not be viewed solely as pandemic response measures,” we told Senate Majority Leader Chuck Schumer, D-N.Y.; Senate Minority Leader Mitch McConnell, R-Ky.; House Speaker Nancy Pelosi, D-Calif.; and House Minority Leader Kevin McCarthy, R-Calif.

    “Without action from Congress, Medicare beneficiaries will abruptly lose access to nearly all recently expanded coverage of telehealth when the COVID-19 PHE ends. This would have a chilling effect on access to care across the entire U.S. health care system,” the letter noted, including on patients who have established virtual health care relationships, “with potentially dire consequences for their health.”

    Among the medical groups, health care networks and corporations co-signing the letter were the AMA, the Mayo Clinic, Amazon and Zoom.

    We joined a similarly broad coalition last June to remind Congress that it “not only has the opportunity to finally bring the U.S. health care system into the 21st century, but the responsibility to ensure that billions of dollars in COVID-focused investments made during the pandemic are not wasted and instead are used to support the transformation of care delivery and, ultimately, expand access to high-quality virtual care to all Americans.”

    The newer letter again emphasizes that telehealth is ubiquitous, popular and efficient, and that there is ample evidence that greater care continuity leads to higher quality of care and lower health care utilization and costs. Again, though, these benefits truly come into relief when the professional on the other end of the line is the patient’s trusted primary care physician.

    It only makes sense, then, to finally remove obsolete restrictions on the location of the patient and the clinician, among other actions for which the Academy has lobbied steadily, particularly this summer.

    CMS’ recently issued 2022 Medicare physician fee schedule proposed rule addresses some of this. As written, it would retain several key services previously added to the Medicare telehealth services list on a temporary basis until the end of calendar year 2023 and permanently allow beneficiaries to receive mental health services via telephone. The Academy is preparing detailed feedback to send the agency, with strong attention to this section of the proposed rule.

    Ultimately, though, Congress must empower regulators to advance permanent telehealth reform. And failure to do so would not be for lack of the Academy’s strong and direct advocacy. Not even three months ago, for instance, AAFP member Kisha Davis, M.D., M.P.H., of Gaithersburg, Md., testified at a Senate Finance Committee hearing titled “COVID-19 Health Care Flexibilities: Perspectives, Experiences, and Lessons Learned.”

    “I want telehealth to be a tool in my toolbox, and I want to choose when and how to deploy it based on my clinical judgment, not based on whether I will get paid,” she said as she entered extensive written testimony into the record. She’s among the family physicians who have definitely learned telehealth lessons and now need lawmakers to listen up.

    Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.


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