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It's the rare Senate hearing when the only disagreements occur not between senators, but between panelists themselves.

Yet that's what happened at Tuesday's on making particular telehealth rules permanent for the Medicare program.

The senators present all agreed on one thing: the current flexible rules for telehealth -- such as paying for audio-only telehealth visits -- should be made permanent for Medicare beneficiaries.

"If you're investing in a health facility, you need to have the predictability to know that these services are going to be able to be continued well before the expiration date," said subcommittee chairman Sen. Ben Cardin (D-Md.). Many of the flexibilities are now set to expire at the end of 2024.

"The COVID-19 pandemic drastically changed our healthcare sector in America and our understanding of how we deliver healthcare," said Sen. Steve Daines (R-Mont.), the subcommittee's ranking member. "Telehealth, which was underused and understudied prior to 2020, suddenly became a crucial means of delivering healthcare services to patients ... Telehealth can help us bolster mental health services and address some of the access gaps throughout the country. It's safe to say there's no going back now, as we've seen how transformative telehealth can be. We have proved the concept."

The only real conflict came when Sen. Todd Young (R-Ind.) asked witnesses which telehealth flexibilities they thought should not be permanently renewed.

"One area that I did not feel that we need to make permanent ... is audio-only visits," said Ateev Mehrotra, MD, MPH, professor of healthcare policy at Harvard Medical School in Boston. "I feel like we can continue to push on the provider community to provide video visits, because I feel like that's the real place that we need to improve care."

Chad Ellimoottil, MD, MS, medical director of virtual care at the University of Michigan in Ann Arbor, quickly jumped in. "I actually disagree," he said. "I do think that audio-only is necessary and should be included."

In his opening testimony, Ellimoottil had listed making audio-only coverage permanent as one of four key factors that could contribute to telehealth's slow decline if left unaddressed. "Recently I experienced this myself in clinic when I attempted to conduct a video visit with a patient from rural Michigan who was experiencing connectivity issues," he said. "After about 5 minutes of troubleshooting, I resorted to picking up the phone and conveyed the exact same information about surgical options for his enlarged prostate over the phone."

"Such scenarios are quite common particularly for Medicare beneficiaries residing in rural and underserved communities," Ellimoottil added. "If audio-only visits become ineligible for billing in the future, healthcare providers will simply not offer them and as a result, Medicare beneficiaries will lose this option for remote care."

The other three factors Ellimoottil listed were:

Lack of coverage alignment among payers. "Medicare sets the standard and many commercial payers follow," he said. "If Medicare continues to view expanded telehealth coverage as temporary, commercial payers will reduce or eliminate their coverage for telehealth services."

Loss of payment parity. "The prevailing narrative suggests that the practice expenses related to telehealth visits are lower than those for in-person visits, thereby supporting the argument for payers to reduce reimbursement rates for telehealth visits," he said. "While on the surface this narrative is quite convincing, the reality is that unless your practice is entirely virtual, it's unlikely that your practice expenses have decreased in a practice where one out of 10 office visits are virtual. Healthcare providers still incur the same costs for maintaining the physical office equipment and salaries of staff, like clerks and nurses who schedule visits, collect records, and provide all the care between visits. Practically speaking, these expenses don't decrease by 10% just because 10% of your visits are now virtual."

Implementation of guardrails that lack clinical evidence. "While we all recognize the importance of preventing fraud and abuse, implementing guardrails -- like mandating periodic in-person visits for patients receiving telehealth services -- only creates barriers for healthcare access," said Ellimoottil. "In 2022, the Office of Inspector General and found that only 0.2% display potentially fraudulent or abusive patterns. There isn't a need to impose in-person guardrails on the 99.8% of healthcare providers who use telehealth without exhibiting any patterns of fraud and abuse."

Eric Wallace, MD, co-director of home dialysis at the University of Alabama at Birmingham, argued that geographic restrictions on telehealth should be eliminated. "Telehealth is for urban and rural [patients]," he said. "I'll never forget a patient of mine who was disabled. The patient lives no more than 2 miles from our clinic, but getting in and out of a vehicle and parking close to our clinic was enough to make any clinic visit a half-day event."

The patient "found an article that I was doing telehealth and he showed me that article; he said 'Is this for me?'" Wallace continued. "And I said 'No,' because he lived in an urban area. Access-to-care problems are not geographically restricted. Why should our regulations be?"

Daines asked witness Nicki Perisho, BSN, program director at the Northwest Regional Telehealth Resource Center in Whitefish, Montana, how telehealth might be able to help fill gaps in healthcare staffing, noting that 100,000 nurses left the profession in 2021, often due to stress and burnout. "Our hospitals have made efforts to support and retain caregivers but the bottom line is they don't have enough caregivers today," he said. "How can telehealth be leveraged to address the severe workforce shortage facing healthcare?"

"I think we're looking at hybrid solutions -- a mix of in-person care and virtual care," said Perisho. "Allowing rural members to have access to specialty care via telehealth is going to be cost-saving on the patient and also on the healthcare side because there's going to be reduced readmissions."

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