The Next Chapter of Telemedicine
Certain policy barriers may limit future adoption of virtual care.
Few industries have seen more dramatic growth in recent years than that of virtual care.
In particular, telehealth’s benefits, including improved access and affordability, have been hard to deny during the pandemic. Policymakers, insurers, and health systems have looked for ways to deliver care virtually to patients since the onset of COVID. The federal government loosened restrictions on telehealth in the Medicare program and the department of Health and Human Services waived enforcement of the Health Insurance Portability and Accountability Act (HIPAA) for telemedicine. Many state governments focused on expanding telehealth in their Medicaid programs as well, relaxing state-level restrictions around provider licensing, online prescribing, and written consent. Now, many of those efforts stand to expire based on reimbursement and regulatory restrictions.
Leader’s Edge sat down with Claudia Tucker, senior vice president of government affairs and Kevin Harper, vice president of government affairs at Teladoc Health, to learn more about their efforts to reduce policy barriers that impact access to care and what they see as the biggest area of opportunity for telemedicine moving forward.
Q
Striking the appropriate balance between in-person and virtual care has prompted the industry to offer up a host of solutions to meet patient needs. What are some of the biggest policy barriers impacting patient access and continuity of care?
A
Tucker: We need to make sure that the modality of care is neutral. As long as the provider can meet the standard of care, the modality shouldn’t matter. Another barrier is that the provider has to be licensed where the patient is at the time of the encounter. There are a lot of waivers that were granted at the state level through various governors’ executive orders that allowed for a provider that was licensed and in good standing in any state to be able to treat a patient. There are some states that saw how well that worked in their state and have since passed legislation. We absolutely support that. Both for general medicine and for behavioral health.
Harper: So much of the conversation at the federal level is really around coverage and payment of these various modalities. And how to incentivize the adoption of technology when delivering healthcare. We are very much focused on traditional Medicare and some of the legacy restrictions on where a patient has to be located geographically.
I think there’s some regulatory reconfigurations that are happening in real time at CMS [with respect to Medicare Advantage]. And folks on Capitol Hill are beginning to take a closer look at the regulations we actually need to account for the fact that every healthcare provider in the country right now is not only delivering care virtually, but also shows a huge appetite to do so in the future.
Then there are the efforts around having a high deductible health plan (HDHP) with a Health Savings Account (HSA) cover virtual care on the pre-deductible basis. It’s a great way to extend access to care for people in those plans and knock down some of the barriers that historically give many workers pause before they reach out and want to talk to a healthcare provider.
Q
Modern Healthcare cites that telehealth utilization dropped an average of 40% per month in 2021 compared to 2020. How is Teladoc re-engaging people in telemedicine for preventive care? How does that help to control costs?
A
Tucker: That’s a great question. In March of 2020, it didn’t take a lot because people were coming to us almost as fast as we could possibly meet their needs. That was an absolute success story to be able to do what we did, at the levels of which we did it, with no preparation.
Now we have watched [utilization] gradually ramp down. But the thing is that people still get poison ivy, they still get upper respiratory infections, they still get UTIs. Virtual care has become even easier to access. We’ve got to make sure that our health plan partners and their employees know about it, and we need to do everything we can to make it as simple as possible, so that when they get ill, the first thing they think about is, “Oh, let me go to virtual care first.”
Harper: I think part of the numbers that you’re seeing around virtual care reflect what traditional healthcare providers had to ramp up and do. Virtually all in-person care turned into telehealth. We delivered more than 15 million virtual visits in 2021, and we’re on track to continue that growth this year. I think a lot of what you’re seeing right now is a transition from what we would call traditional telemedicine that’s very focused on episodic or urgent care. We’re transitioning into really looking at building a unified whole-person care experience.
Tucker: I would be remiss if we didn’t bring up mental health. Pandemic aside, there’s been such a demand for mental health treatment and providers. We all know that there’s a shortage of those and being able to reach these people through virtual care, for many people, has been lifesaving.
Q
Thinking about whole person care and the way that the digital health industry is building a foundation for increasingly connected services, I’m curious how data interoperability fits into the conversation.
A
Tucker: Every conversation that we have with policymakers, state or federal, is concerned about continuity of care. How do you make sure that we don’t make a complex healthcare system even more fractured? In order not to do that, there needs to be guardrails in place and processes to make sure that we’re sharing information with a primary care physician.
I’ve been in this business for a long time. Fifteen years ago, we were talking about interoperability. But I think that we’re making greater strides now because we have to.
Harper: For a company like Teladoc, interoperability is baked into what we do. The challenge is that so much of the healthcare system–even after a decade or more of various of carrot and stick approaches at the federal and state level to incentivize the adoption of interoperable health systems or EHRs–still has a significant segment of healthcare providers operating off of faxes.
I think what you’re starting to see, especially at the federal level, is some real progress in facilitating the adoption of electronic health records that function as they’re supposed to. There are policies that need to be put in place to ensure that patients are able to own their health data and experience a more seamless care experience. We’re going to have to work very hard as the broader telehealth and digital health industry to make sure that patient data is at the heart of what we do. Congress and this administration, and the next administration, have to remain focused on advancing interoperability policy. Because if the foot is taken off the gas, we stand to lose a lot.
Q
The Biden administration is now requesting significant funding and authority tied to mental health services, including a provision that all private health plans cover mental health and substance use disorder and a requirement that mental health costs be comparable to physical health fees. How should telehealth be included in this conversation?
A
Tucker: In the sense that the demand [for virtual behavioral care] is so great. There has not been a single legislator that I’ve talked to who is not concerned about suicide rates in their state, especially college campuses. Make sure that you don’t have any barriers in place. For example, texting is actually a very appropriate way to interact with a patient [who receives mental health treatment] that builds trust, which then allows them hopefully to reach for the phone, then video, and if needed, perhaps an in-person visit. We have got to make sure that we do everything to increase the number of available providers. That means making sure that nurse practitioners can practice at the highest extent of their license, it means dealing with cross state licensure, especially for mental health.
Harper: The pandemic really illustrated how much virtual care was critical. As a stopgap measure to connect patients that had mental health needs to a provider and all of the regulatory flexibilities that were extended, it allowed patients who had never before been able to access a mental health provider, because there are none in their community, or they’re several hours away, access that care.
All of a sudden, all the policies that organizations like ours have been advocating for years around allowing a provider to establish a relationship with a patient virtually or for the payment and coverage policies that would pay for and reimburse that provider for treating a patient virtually, facilitated the greatest expansion of mental healthcare services the country’s likely seen in the past few years. There’s an appetite in this Congress not to lose that [progress] because the impact is so tangible.
Q
Has your advocacy approach evolved at all from the start of the pandemic to now?
A
Tucker: One of the relatively new issues is Medicaid and virtual care. For years, no one thought that virtual care would work for Medicaid. And we’ve since found out that that’s not true. This has led to a realization that while we were working diligently on the commercial side to make sure that the regulations and statutes are up to date, that didn’t happen on the Medicaid side. We are dealing with statutes that never even contemplated virtual care. We’re working in all 50 states now to make sure that they actually reflect what we see in 2022.
Harper: The tension in the conversation is that there are a lot of policy stakeholders who get very focused on the abstract nature of policymaking and budgeting, and they lose sight of the real-world impact on people’s lives. One of our central efforts is to make this policy tangible for policymakers who might look and say, “A Medicare extension for telehealth seems costly. Is that something we should be taking a closer look at?” The nature of the conversation is changing.
