Michelle Danzberger needs a lot of care. The 52-year-old Pennsylvanian has a rare genetic condition that has left her with the IQ of a young child and makes it tough for her to walk. And when she’s anxious, she picks at her skin, causing sores all over her body.
During the pandemic, telemedicine allowed Michelle to connect often with her care providers at Johns Hopkins Medicine, according to her sister, Missy, without traveling two hours to Maryland from their hometown of Chambersburg.
But now Missy worries that changing rules will end the remote visits.
“I don’t know how I’m going to get Michelle to Baltimore,” says Missy, who also cares for two other family members with disabilities. “I honestly just don’t know if I can physically do more than I’m doing already.”
Missy is not alone in her worries. During the pandemic, patients and providers hailed the rapid expansion of telemedicine. But now, many states are stopping emergency regulations, including those that allowed doctors to provide remote care across state lines. And federal agencies that relaxed payment and platform rules may again curtail how telemedicine is delivered.
“By making telehealth difficult to access, we’re making it harder for many patients to get adequate care for many diseases, and that’s just a travesty.”
Nate Gladwell, RN, MHA
Senior director of clinical operations, University of Utah Health Office of Network Development and Telehealth
All this is impacting hundreds of thousands of patients across the United States.
For example, when Virginia’s public health emergency (PHE) ended this summer, some 1,000 patients of Maryland’s Johns Hopkins Medicine could no longer receive remote care. In Boston, Mass General Brigham was forced to cut off telehealth services to thousands of patients this summer because of shifting rules in multiple states.
Meanwhile, some doctors are weighing whether to drop patients or risk practicing without payment or a license. And some patients are driving to nearby states and doing televisits roadside to avoid breaking rules regarding out-of-state doctors.
“By making telehealth difficult to access, we’re making it harder for many patients to get adequate care for many diseases, and that’s just a travesty,” says Nate Gladwell, RN, MHA, senior director of clinical operations for University of Utah Health’s Office of Network Development and Telehealth. “There’s just no way to sugarcoat it.”
The licensing labyrinth
As COVID-19 blazed across the country, nearly every state relaxed their licensing rules so outside physicians could provide telemedicine. Previously, doctors had to complete lengthy forms and pay steep fees to get a license in every state where a patient received remote care.
Now, states are beginning to retighten their licensing rules. At least half have already done so, and others are soon to follow.
At University of Utah Health — which conducted some 100,000 out-of-state telemedicine visits in 2020 — that reality has left doctors scrambling.
Utah neurologist Vivek Reddy, MD, is helping his department figure out how to handle patients from states where loosened rules are ending. Reddy particularly worries about patients reverting to long — and potentially dangerous — trips. He still recalls one disturbing incident from a few years ago. “An eight-hour drive from Nevada to Salt Lake City caused my patient’s blood pressure to drop so low that she had to visit an emergency room along the way,” he says.
Meanwhile, Utah has two staff members working full-time to get doctors licensed in Wyoming, Idaho, and several other surrounding states. The aim is to increase the current number — roughly 300 — to the hoped-for 1,500.
In Pennsylvania, Thomas Jefferson University telehealth leader Judd Hollander, MD, is watching the clock as licensing flexibilities in neighboring New Jersey are set to expire in early 2022. Those rules already ended in nearby Delaware.
“Over one-third of our patients are from surrounding states,” says Hollander. “They come for medical expertise that’s just not available near them. For example, we have a lot of patients with heart failure who need frequent monitoring, and we want to keep them safely at home,” he says. “I’m getting emails from doctors who aren’t licensed in neighboring states, saying, ‘I can’t believe we need to return to the past. This is not right for patients.’”
Getting physicians additional medical licenses is no simple matter.
“The process in some states is extremely tedious, time-consuming, and expensive, and it hampers patient care,” says one New York provider who requested anonymity as he works on his out-of-state licensing.
Meanwhile, that physician is caring for Elliott Terwilliger, a Crohn’s disease patient who moved to Florida and hasn’t been able to find a new gastroenterologist for months. “I trust my doctor. He knows my history and which medications work for me,” says Terwilliger. “If I didn’t have televisits, I’d be lost.”
Of course, states have an interest in setting their own standards for medical licensure, observers note. “State licensing boards are responsible for patient safety and don’t want people practicing willy-nilly without appropriate oversight,” says Helen Hughes, MD, MPH, associate medical director of the Office of Telemedicine at Johns Hopkins Medicine. “Still, that needs to be balanced with the needs of patients.”
“I trust my doctor. He knows my history and which medications work for me. If I didn’t have televisits, I’d be lost.”
As leaders look for licensing solutions, one possibility is interstate agreements. For example, the Interstate Medical Licensure Compact (IMLC), which launched to address the issue even before the pandemic, offers one pathway to licensing in 30 states. Although it’s simpler, the IMLC process still takes time, requiring such steps as fingerprinting, and several large states — California, New York, and Florida among them — don’t participate.
Other options would require congressional action. Some advocates hope for federal legislation enabling cross-state care nationwide during a PHE, removing reliance on individual states to act. Others would go even further, urging legislation that would require reciprocity at all times.
Meanwhile, the confusing patchwork continues for health care leaders like Gladwell. “Unfortunately, unless the federal government comes up with something that meets all stakeholders’ needs, I don’t see a solution anytime soon,” he says.
Before COVID-19, Medicare covered telemedicine only for rural patients — and only if they traveled to certain health care sites. But during the federal COVID-19 PHE, the Centers for Medicare & Medicaid Services (CMS) made a dramatic change: It allowed Medicare coverage of telehealth for any patient, anywhere, as well as payment equal to in-person visits.
That matters not just because Medicare insures 62 million older or disabled Americans but because its actions can influence what state agencies and private insurers decide to do.
Now, a key question is how long the government will extend the PHE declaration. Currently, it’s set to expire in January. “Patients and providers keep watching nervously since the public health emergency needs renewal every three months,” notes Gayle Lee, AAMC director of physician payment policy and quality.
A longer-term solution would be the permanent extension of Medicare’s current telehealth coverage, but that would require congressional action. “Telehealth generally is one of just a few bipartisan issues, so I’m pretty hopeful about possible legislation,” says Jorge Rodriguez, MD, a telemedicine researcher at Boston’s Brigham and Women’s Hospital.
But once the PHE lapses — and if Congress doesn’t pass legislation — Medicare will once again exclude in-home telemedicine and coverage to anywhere other than rural areas. The only exceptions will be most remote substance use and mental health services, which were addressed under prior legislation.
In addition to the geographic issues, observers are watching Medicare’s list of covered services. During the pandemic, CMS added dozens of services — from eye exams to speech therapy — to its list of covered telehealth care. Now the agency is weighing which of those to renew. “The proposal would extend coverage until the end of 2023 to allow further research,” says Lee. “It looks promising, but it’s not completely clear what will be covered.”
Also not completely clear are the intentions of other major telehealth players.
During the pandemic, many states issued rules requiring private insurers to cover virtual visits. As their PHEs end, some states are retaining those coverage requirements — at least temporarily. For example, Maryland is extending many loosened telemedicine rules for more than a year to permit further assessment of the approach.
Even if states continue to require insurers to cover telehealth, a major variable is whether payers will be required — or choose— to reimburse telemedicine at the same level as in-person care. Currently, less than half of states mandate parity for remote care.
Meanwhile, providers are working to help patients understand possible changes in payment rules.
“Insurance plans can be extremely difficult to understand,” says Reddy. “We need to help patients think through the costs for telehealth that aren’t covered versus the expense of missing work and traveling for an in-person visit.
“Our patients often cannot afford to miss even a single day of work and are struggling to meet their basic needs,” he adds. “Travel for an appointment can mean a tremendous financial loss.”
The doctor will Zoom you now
During the pandemic, rules regarding the technological “how” of telemedicine also changed.
For one, the government agreed to stop penalizing providers who use videoconferencing services that don’t meet Health Insurance Portability and Accountability Act (HIPAA) privacy standards. Many providers quickly pivoted to Skype, FaceTime, and other widely available, user-friendly platforms.
As hospitals have been returning to HIPAA-compliant tools, patient advocates urge improving them with easier-to-use features. “We need to make sure platforms are appropriate for people with lower digital literacy, or telemedicine will leave out a chunk of marginalized patients,” warns Rodriguez.
Meanwhile, institutions are working hard to ensure that patients who may struggle with technology can use it. “Some hospitals have even taken on hiring digital health navigators who help patients with such steps as logging onto platforms, positioning their cameras, and otherwise becoming comfortable with telehealth,” Rodriguez says.
“We talk a lot about meeting patients where they are, and telemedicine literally does that.”
Jorge Rodriguez, MD
Telemedicine researcher, Brigham and Women’s Hospital
In some cases, though, videoconferencing is just too tough for patients.
Recognizing that reality, Medicare and many states have permitted audio-only visits during the pandemic. But that’s changing. For example, after the PHE, CMS plans to cover audio-only visits exclusively for mental health services.
Elaine Khoong, MD, MS, a telemedicine researcher and general internist based at Zuckerberg San Francisco General Hospital, worries about the possible loss of audio visits. “I had one older patient who was unable to use video visits despite repeated attempts to set them up, including a social worker going to their home,” she says. “The person also had serious transportation challenges, but during the pandemic, with audio-only, we were able to make progress that we simply could not before.”
Of course, even when a patient’s insurance would cover audio-only telemedicine, some visits simply necessitate internet access, including those in which a provider needs to see a patient’s wound or other physical feature. That has observers concerned about the many patients who lack broadband access, including nearly 30% of rural residents.
Looking ahead, observers note that government funding likely will bolster access to telehealth. In August, the Senate passed the Infrastructure Investment and Jobs Act, which includes $65 billion for extending broadband. The House may vote before the end of the year, but the timing remains uncertain.
Rodriguez hopes patients and health care leaders will speak up about the value of telemedicine. “It’s crucial for patients’ voices to be heard, especially those who are marginalized, to make sure we do right by them,” he says.
“We talk a lot about meeting patients where they are, and telemedicine literally does that.”