“We were able to pivot pretty quickly,” said former operations director Christina R. Quinlan, describing a scramble to add specialized medical and social care.
Across the country, in urban and suburban settings, the same pattern played out as federal and state regulators issued scores of waivers to telehealth access and coverage rules, making it easier for hospitals, health centers and clinics to offer a wider range of remote services and be reimbursed for delivering them.
A question that remains to be answered, experts say, is how many rules will tighten once the public health emergency is over. This summer, more than 430 health-related organizations, including hospitals, professional bodies and patient-advocacy groups, urged congressional leaders to keep open the gateways to telehealth. They argued that much of health-care delivery has moved online “not only to meet COVID-driven patient demand, but to prepare for America’s future health care needs.”
Lawmakers on both sides of the aisle have shown support for making the shift to telehealth permanent through mechanisms such as the Connect for Health Act. But many states have already rescinded the licensing waivers that allowed clinicians and some other providers to practice across state lines, or are preparing to do so. Other decisions at the state, federal and individual health-care system levels remain uncertain.
“It’s frustrating,” said Steven A. Epstein, chair of psychiatry at Georgetown University School of Medicine, who said the pandemic not only fixed logistical challenges for physicians treating patients in adjoining states, but offered many clients welcome convenience when they were able to connect with therapists without having to show up at a clinic.
“The no-show rates dropped off significantly,” said Epstein, who has heard of patients who now drive across state lines to talk to therapists from their cars.
Over the past 18 months, providers have revamped their practices, taking advantage of the pandemic-fueled flexibility that allows consultations in people’s homes rather than in approved clinical settings and via phone instead of only on video. Some have been using platforms that did not meet pre-pandemic standards for privacy and security. Many have invested in new computer systems and signed up for training in a new skill for the modern tech-savvy physician — a good webside manner. (Rx for doctors: Look into the laptop camera, not at the screen.)
“The floodgates opened during covid,” said Danielle Louder, program director for the Northeast Telehealth Resource Center, which supports the growth of telehealth in New England and New York.
Kimberly Brandt, a partner at the consulting firm Tarplin, Downs & Young and former principal deputy administrator for operations and policy at the Centers for Medicare and Medicaid Services, known as CMS, said that in areas such as behavioral health, the uptick has been too big to reverse. But she wondered whether the range of covered services, which expanded to include physical and speech therapy, would continue.
“In general, I do not see us going back,” Brandt said.
For Bernard Forcier, a manager at Portland Glass in Maine, telehealth transformed the chore of traveling to his doctor every three months to monitor his diabetes.
“First thing you know, an hour and a half has gone by and I’ve seen my doctor for 20 minutes,” Forcier said, recalling driving several miles and then sitting in a waiting room. Now he checks in from his own office. “I stop work for 15 minutes. Then I’m right back at it,” he said.
Forcier’s private insurance may well continue to allow him to continue his appointments, but Medicare patients will not be able to if CMS reverts to its pre-pandemic requirement that the “originating site” from which patients consult with doctors is a clinical setting.
“We’ve learned a lot from the covid-19 pandemic, including how telehealth can connect people to care,” a CMS spokesperson said. “As we look forward, CMS will look at expanding access to care with health equity in mind.”
Among many telehealth-related changes CMS is proposing in its 2022 Medicare Physician Fee Schedule, it would allow certain pandemic-era services to continue through 2023 to evaluate whether they should be made permanent.
Some of the proposals could be accomplished through regulatory changes; others would require acts of Congress.
In a Washington Post Live interview, Xavier Becerra, secretary of the Department of Health and Human Services, said: “We are absolutely supportive of efforts to give us the authority to be able to utilize telehealth in greater ways. We want to make sure that we don’t leave anyone behind.”
The striking change during the pandemic was the increased demand for direct-to-consumer care.
At the same time, clinicians took advantage of new flexibility to practice across state lines. Most states lifted the requirement that physicians be licensed in the state where their patient is located — a change that in many states is already being reversed. Use of the Interstate Medical Licensure Compact, an agreement between states that streamlines the process of applying for individual state licenses, grew by almost 50 percent during the pandemic, according to the American Medical Association. But only 30 states belong to the compact, which falls far short of a national licensing system.
The reason for insisting doctors be licensed in their patients’ state is that complaints are handled through state licensing boards.
“The main function of licensure is that it allows states in the current setup to really hold physicians accountable for the care they provide,” said Jack Resneck, president-elect of the American Medical Association, in a Washington Post Live interview.
Still, telehealth’s pandemic-driven rise in popularity reflects patients’ widespread appreciation of flexibility in how and where they seek care. In March and April of 2020, the Mid-Atlantic Telehealth Resource Center, one of 14 Health Resources and Services Administration-funded regional centers, received more than 400 inquiries from providers — an 800 percent jump over the same two months in 2019.
Questions frequently came from clinicians whose patients are covered by Medicare and Medicaid, as CMS issued dozens of waivers of its pre-pandemic regulations, including opening the door to reimbursement for telehealth visits delivered in a patient’s home.
The pandemic also prompted interest from private practitioners, including primary care doctors, who recognize that, going ahead, the ability to provide online visits will be necessary to retain patients and attract new ones, according to Kathy Hsu Wibberly, the Mid-Atlantic center’s director.
“What we are seeing now is private practices missing out on the ability to access patients if they don’t at least have hybrid access of care,” Wibberly said.
What’s holding up progress to even greater use of telehealth is uncertainty about the future web of state and federal regulations over public and private systems.
“That’s the barrier much more than any one thing,” Wibberly said. “Everything is so complex.”
There are signs of support for telehealth. Congress is considering legislation that would make some changes permanent. The $550 billion infrastructure bill that the U.S. Senate passed this month included $65 billion for broadband, which should give patients in rural areas access to Internet connections fast enough for video visits as well as uploading data from wearable medical devices.
And last month, the Biden administration announced a $19 million investment in telehealth in the form of awards aimed at stimulating innovation and expanding access to services in underserved areas.
Among the recipients of the 36 awards is MaineHealth, a nonprofit network that includes community hospitals, physician practices and health-care organizations — and has used telehealth for two decades.
The award will be used to examine the impact of caring for diabetic patients at home, as well as collaborations between primary care physicians and pharmacists.
Last year’s sudden shift to direct-to-consumer care put a new spotlight on primary care — including the shortage of easily used hardware.
“We had IT teams running out to Best Buy 100 miles away to buy video cameras, speaker phones, second monitors,” recalled Jasmine Bishop, MaineHealth’s director of telehealth.
Virtual visits jumped from about 1,200 per month before the pandemic to 30,000 by May 2020, after Medicare lifted its restriction on reimbursing in-home visits.
The new opportunities, including audio visits, also raised concerns from patients, wondering, for example, whether they would be billed for an audio appointment if a physician called with lab results.
“Every time I get a phone call from my doc, am I going to get a co-pay?” Bishop said she would hear.
Bishop uses the digital access to collect data and patient satisfaction surveys, which suggest that for some patients, telehealth will be the best way to provide care for the long term. For the immunocompromised and those seeking mental health care, the clinical setting is always a cause for concern, Bishop said. And many time-consuming urgent care questions, such as checking a tick bite, are more efficiently resolved online.
While Medicare had previously only reimbursed telehealth visits for rural patients, Bishop said virtual care also appeals to urban patients, sometimes because they can’t access city physicians who often have a huge number of patients to choose from.
“There is no geographic restriction on wanting to stay home,” Bishop said.
In many ways, the new enthusiasm for telehealth builds on experience in areas like the Maine islands, where clinicians have long had to figure out ways to treat remote communities.
“We did it because we saw the value of telehealth for access,” recalled Quinlan of the Vinalhaven clinic, which, like other Federally Qualified and Rural Health Centers, had not been paid for delivering telehealth services to Medicare patients until the pandemic.
The most remote island communities have long relied on the nonprofit Maine Seacoast Mission to show up in its 75-foot steel-hulled floating clinic, the Sunbeam V.
The mission’s nurse, Sharon Daley, coordinates with mainland doctors, sometimes consulting with out-of-state specialists like vascular neurologist Anand Viswanathan of Massachusetts General Hospital, who accompanied her on a recent trip to meet patients he usually sees online.
Daley’s experience with everything from unreliable Internet access to physicians’ state-based licensing arrangements is central to a today’s debates in Washington. But day-to-day, her focus is less on policy than on integrating the tools of technology with the traditions of good care — a challenge that all practitioners face as they adapt to telehealth.
That often means acting as an intermediary for physicians whose patients live, literally, out of reach.
“I’m their hands,” Daley said.