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Telehealth rules that have been loosened during the COVID-19 pandemic will likely be extended temporarily before any permanent changes are made, one expert said at a briefing sponsored by the Kaiser Family Foundation.

The public health emergency necessitated by the pandemic itself has been extended through mid-April. In addition, Congress has already extended the telehealth flexibilities for 151 days, or about 5 months, beyond that, explained Krista Drobac, executive director of the Alliance for Connected Care, a lobbying group for telehealth providers. That extension was needed to match up with a temporary increase in Medicaid reimbursement for U.S. territories, she said at the Tuesday event.

Congress also required the Medicare Payment Advisory Commission (MedPAC) and the Office of Inspector General (OIG) at the Department of Health and Human Services to report on how well the telehealth flexibilities are working, but those reports aren't due until June 2023, Drobac said. "I do not believe that Congress will make permanent changes to the law without real analysis by MedPAC or OIG, so our expectation is that the next action ... will be another extension. And then once those reports come out, and more peer-reviewed analysis comes out of what happened during the pandemic, then we'll lobby on permanent changes."

Telehealth flexibilities for the Medicare program that have been in place during the pandemic include:

• Fewer restrictions on where telehealth could be provided -- previously Medicare would only reimburse for telehealth services provided to rural beneficiaries, and the beneficiary had to go to a medical facility to receive the service; those rules were relaxed during the pandemic. As a result, in 2020, "we had 28 million [telehealth] visits by Medicare beneficiaries; that compares to less than 350,000 visits in 2019," said Drobac.
• More Medicare provider types were able to use telehealth, including speech therapists, occupational therapists, and physical therapists.
• The Drug Enforcement Administration loosened its restrictions on medication prescribing via telehealth, including requiring an in-person visit prior to prescribing controlled substances -- a change that affected mostly behavioral health patients, she said.
• Medicare allowed audio-only telehealth to be reimbursed.

Private employers "were much further ahead than Medicare in terms of offering telehealth," Drobac added. "On the commercial side, employers were able to offer discounted telehealth services to people with health savings accounts. There are 35 million Americans in the commercial market with health savings accounts, and they were able to access telehealth before the deductible."

Another issue for telehealth providers related to state licensure. Before telehealth became popular, it wasn't a problem if state law required physicians to be licensed in the state where they treated patients, because all of the patients were visiting physicians in person, said Ateev Mehrotra, MD, associate professor of healthcare policy and medicine at Harvard Medical School in Boston. "During the pandemic, all of a sudden that became a very new issue for the patients that I cared for in another state; I wasn't licensed in that state."

To accommodate telehealth, "almost all the states in the U.S. made a temporary change at the start of the pandemic, saying, 'Patients in our state can be cared for by a physician in another state,'" he said. "And so early on in the pandemic, Americans from all over the country started having telemedicine visits with physicians in other states."

However, in the spring and summer of 2021, "a lot of those temporary expansions started to lapse," said Mehrotra. "And there was a lot of frustration among Americans because they were used to having telemedicine visits to a physician in another state, and all of a sudden they would get an email from their doctor saying, 'You need to be in my state if I'm going to care for you.' And so they had to now go to the office, or -- very awkwardly -- go to a rest area, cross over and pull into the other state, and have a visit."

There are several options to deal with this problem, according to Mehrotra: one is for states to make permanent the change they made during the pandemic to allow their residents to be cared for by a physician in another state, a rule known as "automatic reciprocity." Another option is an "interstate medical licensure compact" -- already on the books in more than 30 states -- in which it becomes easier for a physician in one state within the compact to get a license in another compact state. And at the federal level, the federal government -- or at least the Medicare program -- could mandate the "automatic reciprocity" among states. He added that there was one other option but it was probably the least likely of all: a single national medical license.

Regarding the "interstate compact" option, Drobac said her group was working on Congressional legislation "that will instruct the Department of Health and Human Services to set up the infrastructure for sort of a 'driver's license' type of compact that would be a national infrastructure, but would be voluntary for states to join." The arrangement would be "something that balances patient access with patient safety ... and it's not the federal government telling states what to do or interfering in interstate commerce, but actually setting up an infrastructure for them to be part of. That will be introduced in the Senate in the coming months," she said.

The pandemic also highlighted the health equity issues related to telehealth, said Sinsi Hernández-Cancio, vice president for health justice at the National Partnership for Women & Families. "There's a huge issue with broadband infrastructure in this country. And while we often see reports about where there's broadband available at any price, that is not the measure that we need to look at -- we need to look at where there is affordable broadband, and that's very, very different."

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