To Achieve Healthcare Equity, Telehealth Must Be Expanded To Rural And Underserved Communities

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The coronavirus pandemic has ushered in a boom for telehealth, with its future now being shaped by Congress and federal policy.

The need and the challenges for telehealth use in rural and underserved communities are the focus of a House Ways and Means Committee Rural and Urban Underserved Task Force. On Thursday, the task force held a roundtable discussion, “Examining the Role of Telehealth during COVID-19 and Beyond.”

“The greatest threat to healthcare equity may be not taking action to expand telehealth for the most vulnerable,” said Dr. Jason Tibbels, chief quality officer for Teladoc, a leading telehealth provider.

Reform efforts must be coupled with significant and targeted investment to bridge the digital divide and to remove barriers for underserved populations, he said. But telehealth is not a silver bullet to solve social and structural challenges in healthcare, Tibbels added.
Committee Co-chair Rep. Dr. Brad Wenstrup, R-Ohio, said rural hospitals have a skewed payment system because they don’t receive as much revenue as other hospitals and have lower volume.

Ways and Means ...
... Worker and Family Support Subcommittee Chairman Danny K. Davis, D-Ill., focused on the community health centers that serve more than 28 million low-income and disproportionately uninsured patients in rural and underserved urban areas.

Many have inadequate broadband services, Davis said. They are not using telehealth because: 36% of center personnel say they lack reimbursement; 23% cite lack of funding for equipment; and 21% lack training for providing telehealth.

“More rural than urban clinics reported inadequate broadband services,” Davis said.

Many have not fared well during the pandemic, with the result that 1,900 are temporarily closed.

A recent JAMA report found that 41% of consumers lack high-speed internet access, said Committee Co-chair Rep. Jodey Arrington, R-Texas.

“There’s already bipartisan consensus on several legislative proposals for telehealth,” said Rep. Mike Thompson, D-Calif., citing the bipartisan Protecting Access to Post-Covid-19 Telehealth Act he and others introduced in July.

WHY THIS MATTERS

For providers, one of the most important considerations in continuing telehealth is the parity of payment that currently exists between an in-person physician visit and one conducted virtually. This ends when the public health emergency is lifted.

The Centers for Medicare and Medicaid Services recently proposed changes to expand certain telehealth flexibilities permanently, especially in rural areas, in the 2021 Physician Fee Schedule Proposed Rule. The proposed rule was released just after President Trump’s executive order on Improving Rural and Telehealth Access.

CMS made no mention in the proposed rule on whether the parity payment aspect will remain.

One reason this is so important is because of the cost to hospitals and physician practices to implement the technology, staffing and training needed for the infrastructure to work within privacy standards.

“Many providers are deciding it’s not worth it because they don’t know if they will be reimbursed post-pandemic,” said Dr. Ateev Mehrotra, associate professor in the Department of Health Care Policy of Harvard Medical School.

Also in question is the continued high utilization of telehealth. The current use of telemedicine is half of what it was at its peak, Mehrotra said. He believes telehealth works in those cases in which a patient has barriers to seeing a physician in-person, such as in nursing home visits, but otherwise coverage should be selective and its payment should reflect the lower cost.

Tibbels agreed that telehealth use has decreased since its early highs during the pandemic, but said the new status quo is much higher than pre-COVID-19 levels.

In some states where the curve is flattened, Teladoc is seeing twice as many patients this year as last.

“We’re seeing sustained demand in areas no longer considered hot spots,” Tibbels said.

What’s needed, Tibbels and others said, is to remove site restrictions that limit where telehealth visits can take place.

Some remain skeptical that telemedicine will reduce overall healthcare spending by replacing in-person visits.

One way to help solve concerns over the increased utilization of telehealth is to implement value-based payment around it, including alternative payment models, several said during the roundtable discussion.

THE LARGER TREND

Another telehealth roundtable was held Thursday in Boston by CMS Administrator Seema Verma, a member of the White House Coronavirus Task Force.

Verma convened the roundtable with Boston-area healthcare leaders, including representatives from American Well, Blue Cross Blue Shield of Massachusetts, Mass General Brigham, Massachusetts Health Data Consortium, Massachusetts Health and Hospital Association, Massachusetts Health Quality Partners, Needham Wellesley Family Medicine, and UMass Memorial Health Care.

Participants described the ways providers are using telehealth, from ICU consults to helping to preserve personal protective equipment, to primary care providers maintaining access to care for their patients with chronic conditions, to expanded access to mental health services.

For the Ways and Means Task Force, the roundtable is intended to be the first of several to address four top policy areas: addressing direct social determinants of health, enacting payment system reforms, strengthening technology and infrastructure, and reinforcing the workforce.

“There are many issues demanding our attention these days. But there are few as important as expanding access to quality healthcare,” said Task Force Co-chair Rep. Terri A. Sewell, D-Ala.

Ways and Means Committee Chairman Richard E. Neal, D-Mass., who established the task force said, “To ensure telehealth can work for all, we need strategic investments in infrastructure, as well as diligent attention to ensure that telehealth does not exacerbate existing disparities among the populations that are the focus of the Rural and Underserved Communities Health Task Force.”