House Members Struggle to Craft Road Map for Future of Telehealth

Telehealth is here to stay, but deciding how to pay for it, how to deliver it across state lines, and how to prevent it from eclipsing in-person care remain ongoing issues, said lawmakers and witnesses during a hearing of the House Energy & Commerce Subcommittee on Health on Wednesday.

In January 2020, less than 1% of medical care and treatment involved telehealth, but from March to April 2020, with the start of the COVID-19 public health emergency, 80% of all health visits suddenly became telehealth visits, according to a subcommittee memo. Those figures have fallen significantly since their peak, with only about 16% of Medicare beneficiaries using telehealth from late 2021 to mid-2023.

Pandemic-era telehealth flexibilities extended under the Consolidated Appropriations Act of 2023 are slated to end on December 31. With that deadline looming, Subcommittee Chair Rep. Brett Guthrie (R-Ky.) said the committee is looking to advance long-term solutions for a new telehealth framework. To that end, members have introduced 15 different bills.

Subcommittee Ranking Member Rep. Anna Eshoo (D-Calif.) said that the changes that HHS made during the pandemic have set the standard and encouraged private insurance to follow suit.

“This is not a partisan issue,” she added.

During the hearing, witnesses collectively agreed that the expansion of telehealth has been, on the whole, a success.

Lee Schwamm, MD, of the Yale School of Medicine in New Haven, Connecticut, likened telehealth to a “backup generator that kept the lights on and averted a potential secondary healthcare disaster.”

With the workforce shrinking and demand growing, modernizing the healthcare system to make it more resilient should be a “major national priority,” he said. Failing to make pandemic-era telehealth waivers permanent will lead to “a tragic loss of access to care for Medicare beneficiaries,” he added.

Eve Cunningham, MD, MBA, chief of virtual care and digital health at health system Providence, was direct in her message: “The most important thing that Congress can do this year is make the Medicare telehealth flexibilities that you have enacted and extended on a bipartisan basis permanent.”

The telehealth flexibilities expected to expire at the end of the year include the following:

• Telehealth services in the home for Medicare patients
• The elimination of geographic restrictions for an originating site for non-behavioral or non-mental health services (restrictions on behavioral/mental health services have already been made permanent)
• Telehealth services by all eligible Medicare providers
• Federally qualified health centers and rural health centers

As Guthrie pointed out during his opening statement, several of the committee’s bills, including the Telehealth Modernization Act, would permanently eliminate originating site requirements. Another would expand the types of clinicians eligible to provide care via telehealth to include physical therapists, occupational therapists, and others.

Reimbursement

One area where there was some disagreement was payment.

Ateev Mehrotra, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, argued that telehealth must be reimbursed at a lower rate than in-person care.

In Medicare, payments are based on the time a clinician spends with the patient, as well as the space, staff, and equipment used. While telehealth involves some overhead, those visits do not require the same practice expenses, he argued.

“If something costs less, we should be paid less,” Mehrotra said. This is especially true, given that paying in-person rates for telehealth could lead some physicians to give up their physical practice space, which would reduce patient choice, he added.

Rep. Larry Bucshon, MD, (R-Ind.) a cardiothoracic surgeon, countered that paying “substantially less” for telehealth would lead providers to “quit doing it.”

Cunningham, who was asked whether hospitals would continue to provide telehealth if they were reimbursed at half the rate of in-person visits, argued that telehealth has its own expenses, including “the implementation, the workflow redesign, the change management, licensing, credentialing, [and] ensuring that you have billing and compliance and administrative costs as well.”

Patient Choice

Rep. Frank Pallone Jr. (D-N.J.) acknowledged the need for telehealth in rural and hard-to-reach communities, but noted that he prefers in-person care, adding that he believes most people prefer to see their doctor face-to-face.

And Rep. John Sarbanes (D-Md.) warned that Congress must ensure “robust consumer protections” for seniors and avoid undermining network adequacy standards. “Telehealth, if it’s not deployed well, can be used to cut corners in ways that negatively affect patients’ health,” he said.

Fred Riccardi, president of the Medicare Rights Center, shared Sarbanes’ concerns around maintaining adequate provider networks. “We have to make sure that we don’t allow telehealth companies to meet those standards and inadvertently erode access to in-person care,” he said.

On a separate issue, Pallone asked if there were services that should be rendered in person rather than via telehealth.

Riccardi pointed to Medicaid long-term care and hospice, which he stressed are both “high-risk” and “high-touch” services. In these cases, seeing a person in their home environment and observing their activities of daily living matter, he said. “And I think this is an area where we should really be cautious in waving in-person assessments,” he argued.

Licensing and Limits of Telehealth

Finally, lawmakers broached the thorny issue of licensing. Broadly, physicians must be licensed in the state where their patients are located, with some exceptions.

Mehrotra said this creates a problem for telehealth, with some patients making their telehealth visits in parking lots across state borders rather than in their homes, due to their physicians’ fears of liability.

He called on Congress to develop exceptions for licensure mirroring 2017 legislation targeting sports medicine physicians. He clarified that anyone granted such an exception would still need to be licensed and in good standing in the state where he or she is located.

Schwamm proposed changing the definition for “site of care” to the place where the clinician is located, rather than the patient, which he admitted was a “radical” change.

But “it makes no sense to anchor it where the patient is located. The care is being rendered and prescribed where the provider is located,” he said.

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