COVID-19 and Telehealth: Will the Expansion Persist After the Pandemic?

Prior to the coronavirus disease 2019 (COVID-19) pandemic, restrictions on telehealth services significantly limited patients from interacting virtually with health care providers. Providers were only permitted to bill Medicare for telehealth visits under certain circumstances based on an extremely narrow list of covered services.^1,2 For example, patients living in rural areas with limited access to care were able to travel to a local medical facility to obtain services from a provider in a remote location. In general, telehealth services provided in patients’ own homes were not permitted. In addition, providers were often skeptical of providing telehealth services on potentially nonsecure video and audio platforms due to the legal issues surrounding patient privacy under the Health Insurance Portability and Accountability Act (HIPAA).

Beginning in March 2020, however, President Trump announced an emergency declaration under the Robert T. Stafford Disaster Relief and Emergency Assistance Act.³ In conjunction, the CMS expanded Medicare’s telehealth benefits under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act.⁴ As a result of the expansion, the list of covered telehealth services was broadened significantly—it now temporarily includes common office visits, mental health counseling, and preventive health screenings. Beneficiaries can receive any of these telehealth services in any health care facility, as well as from their homes.

These services are paid under the physician fee schedule at the same amount as traditional in-person services. Several commercial insurance companies are following suit in their expansion of covered services. In addition to the waiver issued by CMS, the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) stated it will now use increased discretion and waive potential penalties when enforcing HIPAA violations, specifically within the context of COVID-19 and telehealth.⁴ In other words, a provider may now, in good faith, use any nonpublic facing audio or video platforms—such as Apple FaceTime, Skype, Google Hangouts, etc.—that may not otherwise be considered HIPAA compliant without fear of repercussion.

While the ongoing pandemic appears to be far from over, the expansion of telehealth is still only a temporary measure implemented for use during the national emergency. Going forward, it will be important for both patients and providers to weigh the pros and cons of telehealth in order to advocate for or against future legislation.

Potential Benefits of Telehealth

Perhaps one of the most relevant benefits of telehealth during the ongoing pandemic is increased safety of both patients and providers. By using virtual platforms, social distancing measures can be easily enforced to reduce potential infectious exposures. For example, rather than overwhelming facilities in person, patients who may have symptoms of COVID-19 can now use telehealth services to be screened and referred as appropriate. This not only decreases unnecessary provider exposure but also lowers the risk of transmission to patients needing in-person appointments for non-COVID-19 conditions. In addition to increased safety, telehealth services preserve personal protective equipment (PPE), which is extremely valuable given the ongoing shortage.

The potential benefits of telehealth are not limited to the setting of the global pandemic. In fact, telehealth services can be used in a variety of situations to improve access to care, increase convenience, and decrease travel-related costs for patients and PPE-related costs for providers. Some possible telehealth services listed by the CDC include:⁵

• Providing low-risk urgent care, identifying those persons who may need additional medical consultation or assessment, and referring as appropriate
• Accessing primary care providers and specialists, including mental and behavioral health, for chronic health conditions and medication management
• Providing coaching and support for patients managing chronic health conditions, including weight management and nutrition counseling
• Participating in physical therapy, occupational therapy, and other modalities as a hybrid approach to in-person care for optimal health
• Monitoring clinical signs of certain chronic medical conditions (eg, blood pressure, blood glucose, other remote assessments)
• Engaging in case management for patients who have difficulty accessing care (eg, those who live in very rural settings, older adults, those with limited mobility)
• Following up with patients after hospitalization
• Delivering advance care planning and counseling to patients and caregivers and documenting preferences if a life-threatening event or medical crisis occurs
• Providing nonemergent care to residents in long-term care facilities

Utilization of telehealth services has already been shown to improve health outcomes. One study utilizing telehealth demonstrated a 73% relative reduction of all-cause hospital readmission among heart failure patients in 3 years.⁶ In addition, multiple professional medical societies, including the American Medical Association and the American Academy of Pediatrics, have endorsed the utilization of telehealth services. However, while the potential benefits of telehealth are vast, it does not come without barriers.

Potential Barriers to Telehealth

A few of the potential barriers to telehealth are merely technical in nature. Perhaps the one that can be most easily overcome is the low level of comfort with the audio and video platforms being used. Providers should ideally be comfortable using a variety of platforms so that patients may choose whichever application they are most familiar with. This will help ease the transition from traditional in-person visits to virtual communication. Another technical barrier that may not be so easily overcome is some patients’ lack of access to a technological device—such as a smartphone, tablet, or computer—or Internet access needed for the telehealth service.⁵

Another potential barrier to the uptake of telehealth services by providers relates to issues with interstate licensure. For example, when a provider is in one state and the patient is in another, which state is the focus for law governing the relationship? In general, all states require telemedicine providers to be licensed domestically prior to delivering services to patients located in their state. While 29 states have joined the Interstate Medical Licensure Compact, which enables expedited licensure for providers to practice across state lines, there are still 21 states that have not.⁷ Staying current with regulations and waivers on a state-by-state basis continues to be a time-consuming challenge for providers and their staff.

Last is the quality of care delivered via telehealth in comparison to that of a traditional in-person visit.⁸ Some providers are skeptical of telehealth replacing face-to-face communication due to difficulties building and maintaining provider-patient relationships. Arguably, that trust is built most effectively through in-person relationships. In addition, only being able to see and hear patients through a screen and speaker limits providers’ abilities to appraise the whole patient. The inability to perform a physical exam and observe the patient nonvirtually may be an issue that cannot be overcome.

Conclusion

The temporary expansion of telehealth services has undoubtedly proven beneficial during COVID-19 in regard to increasing patient and provider safety and preserving PPE. However, will the expansion persist after the pandemic? If the expansion does persist, will the benefits? As of now, researchers are predicting a 7-fold growth in telehealth by 2025.⁹

It will be interesting to see which health care settings experience a surge in virtual care and which do not. Some experts are predicting a large increase in ‘virtual urgent care’ which will in turn decrease unnecessary emergency department visits and decrease health care-associated costs.¹⁰ However, traditional in-person visits to primary care providers and specialists managing chronic conditions may not be easily replaced by telehealth, or at least not completely. Finding a balance between traditional and virtual visits that maximizes the benefits of telehealth while minimizing its barriers will be of utmost importance going forward.

Taylor R. Elliott is a 2021 PharmD/MPH candidate at the University of Kentucky Colleges of Pharmacy and Public Health in Lexington.Joseph L. Fink III, BSPharm, JD, DSc (Hon.), FAPhA, is a professor of pharmacy law and policy and the Kentucky Pharmacists Association Endowed Professor of Leadership at the University of Kentucky College of Pharmacy in Lexington.

REFERENCES

• President Trump Expands Telehealth Benefits for Medicare Beneficiaries During COVID-19 Outbreak [news release]. Baltimore, MD; March 17, 2020: CMS website. https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak. Accessed July 28, 2020.
• Milenkovic N. Pandemic Prompts Government to Expand Telemedicine. Pharmacy Times. https://www.pharmacytimes.com/publications/issue/2020/May2020/pandemic-prompts-government-to-expand-telemedicine. May 22, 2020. Accessed July 28, 2020.
• Letter from President Donald J. Trump on Emergency Determination Under the Stafford Act. The White House [news release]. Washington, DC; March 13, 2020. White House website. https://www.whitehouse.gov/briefings-statements/letter-president-donald-j-trump-emergency-determination-stafford-act/. Accessed July 28, 2020.
• HHS. Telehealth: Delivering Care Safely During COVID-19. HHS website. https://www.hhs.gov/coronavirus/telehealth/index.html. Published July 15, 2020. Accessed July 28, 2020.
• CDC. Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. Centers for Disease Control and Prevention. CDC website. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html. Updated June 10, 2020. Accessed July 28, 2020.
• O’Connor M, Dempsey M, Huffenberger A, et al. Using Telehealth to Reduce All-Cause 30-Day Hospital Readmissions among Heart Failure Patients Receiving Skilled Home Health Services. Applied Clinical Informatics. 2016;07(02):238-247. doi:10.4338/aci-2015-11-soa-0157
• Interstate Medical Licensure Compact. Physician License. IMLC website. https://www.imlcc.org/. Accessed July 28, 2020.
• Blumenthal D. Where Telemedicine Falls Short. Harvard Business Review. https://hbr.org/2020/06/where-telemedicine-falls-short. Published June 30, 2020. Accessed July 28, 2020.
• Miliard M. Telehealth set for 'tsunami of growth,' says Frost & Sullivan. Healthcare IT News. https://www.healthcareitnews.com/news/telehealth-set-tsunami-growth-says-frost-sullivan. Published May 19, 2020. Accessed July 28, 2020.
• Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: A quarter-trillion-dollar post-COVID-19 reality? McKinsey & Company. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality?cid=Covid-19-eml-alt-mip-mck. Published June 1, 2020. Accessed July 28, 2020.