“CEO Action for Racial Equity was one of 430 organizations who signed on to this industry letter to Congress to push for action ahead of the upcoming telehealth cliff.”

July 26, 2021

–

–

Thank you for your leadership in expanding access to telehealth during the COVID-19 public health emergency
Dear Congressional Leaders:RE: Priorities for Medicare Telehealth Reform

(PHE). Driven by swift action from Congress, the flexibilities enabled under the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 and the Coronavirus Aid, Relief, and Economic Security (CARES) Act have allowed clinicians across the country to scale delivery and provide all Americans — many for the first time — access to high quality virtual care. In response, health care organizations across the nation have dramatically transformed and made significant investments in new technologies and care delivery models, not only to meet COVID driven patient demand, but to prepare for America’s future health care needs.

Unfortunately, this progress is in jeopardy. Many of the telehealth flexibilities are temporary and limited to the duration of the COVID-19 public health emergency. Without action from Congress, Medicare beneficiaries will abruptly lose access to nearly all recently expanded coverage of telehealth when the COVID-19 PHE ends. This would have a chilling effect on access to care across the entire U.S. health care system, including on patients that have established relationships with providers virtually, with potentially dire consequences for their health.

Telehealth is not a COVID-19 novelty, and the regulatory flexibilities granted by Congress must not be viewed solely as pandemic response measures. Patient satisfaction surveys and claims data from CMS and private health plans tell a compelling story of the large-scale transformation of our nation’s health care system over the past year and, importantly, demonstrate strong patient interest and demand for telehealth access post-pandemic:

• Telehealth is ubiquitous with more than 1 in 4 (15 million) of all Medicare beneficiaries accessing telehealth between the summer and fall of 2020.[1] Telehealth represented 0.22 percent of all medical claims for private health plans in December 2019, rising to 6.51 percent by December 2020.[2] In response, private payers are moving to expand telehealth post-pandemic[3] and meet new expectations from employers and plan members.[4]
• Telehealth is popular with MedPAC noting that 91% of Medicare beneficiaries were satisfied with their telehealth video visits in its March 2021 report to Congress.[5] Patient satisfaction with telehealth across specialties and programs was high pre-pandemic[6] and has remained so during COVID-19.[7] 75 percent of Americans now report having a strong interest in using telehealth moving forward.[8]
• Telehealth is efficient with no-show rates for telehealth visits (7.5%) during the COVID-19 pandemic lower than both the no-show rates for in-office visits (36.1%) and a pre-pandemic in-office no-show rate (29.8%).[9] Providers and health systems continue to report on the significant and positive impact virtual care has had on operational efficiencies.[10]
• Telehealth can help address existing health disparities and during the pandemic GAO found that the proportion of beneficiaries utilizing telehealth was relatively equal across racial and ethnic groups.[11] While investment is needed to address the digital divide – including broadband and funding for end user devices –researchers found significant value in leveraging telephone visits in extending access to underserved populations and enhancing FQHCs abilities to meet patient needs.[12] Before COVID-19, telehealth was seen as an important tool to deliver care to patients that had challenges with transportation, balancing responsibilities with hourly and seasonal jobs, accessing culturally sensitive providers, and – for the 46 million Americans in rural areas – traveling extreme distances to specialty and emergency care.[13]

With so many patients accessing care virtually, expectations for the future of our health care system have shifted significantly. Virtual care has provided unprecedented access for patients, but uncertainty as to the future of many telehealth policies will halt or reverse further adoption – to the detriment of both patients and providers. Congress not only has the opportunity to bring the U.S. health care system into the 21st century, but the responsibility to ensure that the billions in taxpayer funded COVID investments made during the pandemic are not simply wasted but used to accelerate the transformation of care delivery, ensuring access to high quality virtual care for all Americans.

Given the statutory restrictions in Section 1834(m) of the Social Security Act, Congress must act to ensure that the Secretary has the tools to transition following the end of the public health emergency and ensure telehealth is regulated the same as in-person services. Secretary Becerra has recently asked for such authority,[14] and we urge bipartisan action toward this goal.

With these critical issues in mind, we ask that Congress advance permanent telehealth reform focused on the following priorities, at a minimum:

1. Remove Obsolete Restrictions on the Location of the Patient and Provider. Congress must permanently remove the Section 1834(m) geographic and originating site restrictions to ensure that all patients can access care where they are. The response to COVID-19 has shown the importance of making telehealth services available in rural and urban areas alike. To bring clarity and provide certainty to patients and providers, we strongly urge Congress to address these restrictions in statute by striking the geographic limitation on originating sites and allow beneficiaries across the country to receive virtual care in their homes, or the location of their choosing, where clinically appropriate and with appropriate beneficiary protections and guardrails in place.
2. Maintain and Enhance HHS Authority to Determine Appropriate Providers, Services, and Modalities for Telehealth. Congress should provide the Secretary with the flexibility to expand the list of eligible practitioners who may furnish clinically appropriate telehealth services. Similarly, Congress should ensure that HHS and CMS maintain the authority to add or remove eligible telehealth services – as supported by data and demonstrated to be safe, effective, and clinically appropriate – through a predictable regulatory process that gives patients and providers transparency and clarity. Finally, Congress should give CMS the authority to reimburse for multiple telehealth modalities, including audio-only services, when clinically appropriate.
3. Ensure Federally Qualified Health Centers, Critical Access Hospitals, and Rural Health Clinics Can Furnish Telehealth Services After the PHE. FQHCs, CAHs, and RHCs provide critical services to underserved communities and have expanded telehealth services after restrictions were lifted under the CARES Act and through executive actions. Congress should ensure that FQHCs, CAHs, and RHCs can offer virtual services post-COVID and work with stakeholders to support fair and appropriate reimbursement for these key safety net providers and better equip our health care system to address health disparities.
4. Remove Restrictions on Medicare Beneficiary Access to Mental and Behavioral Health Services Offered Through Telehealth. Without Congressional action, a new requirement for an in-person visit prior to access to mental health services through telehealth will go into effect for most Medicare beneficiaries. We urge Congress to reject arbitrary restrictions that would require an in-person visit prior to a telehealth visit. Not only is there no clinical evidence to support these requirements, but they also exacerbate clinician shortages and worsen health inequities by restricting access for those individuals with barriers preventing them from traveling to in-person care.[15] Removing geographic and originating site restrictions only to replace them with in-person restrictions is short-sighted and will create additional barriers to care.

We look forward to working with you to build on the temporary telehealth expansion enacted in the Coronavirus Preparedness and Response Supplemental Appropriations Act and the CARES Act to provide certainty to our nation’s health care providers and, more importantly, ensure Medicare beneficiaries can continue to access care when and where they need it. Congress must act before the PHE expires or providers and patients will lose access to high-quality virtual care.

Sincerely,

[1] https://www.kff.org/medicare/issue-brief/medicare-and-telehealth-coverage-and-use-during-the-covid-19-pandemic-and-options-for-the-future/

[2] https://www.prnewswire.com/news-releases/telehealth-claim-lines-increase-2-817-percent-nationally-when-comparing-december-2019-to-december-2020–301241089.html

[3] https://www.ahip.org/using-telehealth-to-deliver-affordable-high-quality-care/

[4] https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0031

[5] http://medpac.gov/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf

[6] https://pubmed.ncbi.nlm.nih.gov/26269131/

[7] https://c19hcc.org/telehealth/patient-survey-analysis/

[8] https://c19hcc.org/telehealth/patient-survey-analysis/

[9] https://www.liebertpub.com/doi/10.1089/tmj.2021.0002

[10] https://www.ama-assn.org/system/files/2021-05/ama-return-on-health-report-may-2021.pdf

[11] https://www.finance.senate.gov/imo/media/doc/Jessica%20Farb%20GAO%20Testimony.pdf

[12] https://jamanetwork.com/journals/jama/fullarticle/2776166

[13] https://www.cdc.gov/ruralhealth/about.html

[14] https://www.c-span.org/video/?c4966006/user-clip-sec-becerra-telehealth

[15] https://www.americantelemed.org/wp-content/uploads/2021/06/ATA-Overview-of-In-Person-Requirements-1.pdf