Centering on Coronavirus Podcast: The Expansion of Telehealth
Traditionally a supplementary and underutilized form of health care delivery, telehealth is now one of the frontline pillars of defense against the COVID-19 pandemic. In April 2020, a Morning Consult poll found that 23% of adults have used telemedicine services since the outbreak of COVID-19, and virtual visits surged 50% in March 2020, compared to February. By keeping patients away from busy hospitals, telehealth is helping to reduce the burden on overwhelmed care centers and the risk of infections. However, the potential applications of telehealth extend far beyond this crisis. It could help ease longstanding problems with health care costs and accessibility, particularly in underserved communities. Today, New Center policy analyst Olive Morris checks in with Mei Kwong with the Center for Connected Health Policy to explore the potential of telehealth during and after the crisis.
Olive Morris: [01:03] Can you introduce yourself and your organization?
Mei Kwong: [01:05] Sure. My name is Mei Kwong, the executive director of the Center for Connected Health Policy, which is the federally designated National Telehealth Policy Research Center.
OM: [01:14] Telehealth has sort of a long history. It’s been around in some capacity for decades. Yet, it wasn’t necessarily widespread until recently and it may be a new concept for some of our listeners. Can you just tell us exactly what telehealth is and the different forms that it may take?
MK: [01:33] Sure, telehealth is really using technology to provide some sort of health care service where the patient and the doctor or whatever home health care provider you may be engaging with aren’t in the same location. So you’re just using technology to connect with each other and you’re just not there in person each other.
It has different types of forms in which it can use technology and deliver that service. The most common one and probably the most that people are familiar with is called live video, which is exactly what it sounds like, a real time live video interaction between the two parties. Then there are other modalities, other ways of delivering the services. One is a not in real-time service that’s called store-and-forward, which is kind of self-explanatory. You store some type of information and you forward it to the provider who is not looking at it like right when it comes in, but maybe at a later time.
So, for example, you see your primary care doctor and you have a skin condition and you’re not quite sure what it is. They take a picture of it and they send it over a secure system to a dermatologist. The dermatologist isn’t looking at it right when that email comes in or that message comes in. They may be looking at it at later time. Then a dermatologist looks at it and sends the recommendation or diagnosis back to the primary care doctor. So you’re storing and forwarding some information.
Then the other way of delivering care is something called remote patient monitoring. So that’s a continuous monitoring of a patient and it can be in real-time and not in real-time. So a real time example is if you’re in an ICU unit, you’re intensive is the doctor there, the ICU doctor, who may not be right at that location with the patient at that time, but maybe as monitoring from a different location. But they are doing it in real-time and they’re communicating back and forth with health care personnel, who are there on location with the patient and doing what needs to be done physically.
And then a non-real-time example of how patient monitoring is: think of somebody who maybe has a chronic condition, such as high blood pressure. Your doctor wants to know what your readings are for a period of time to see if maybe medication is working out for you or if you’re experiencing any type of issues. So you’re at home, you’re taking readings, and you’re sending them to your provider. Maybe, you’re doing it like once a day or you’re sending all the readings at the end of the week. Again, the provider probably isn’t looking at them as those readings are coming in, but maybe looking at a later time. Not in a real-time example, like continuous monitoring.
OM: [04:19] Ok, so then what types of modalities do you feel are most commonly being used in telehealth right now?
MK: [04:27] Live video is definitely the most popular one. It’s the one that probably most people are familiar with. It’s the one that you’re talking about people or payers such as Medicare, Medicaid or commercial payers, it’s what they cover it. If they cover any services delivered by telehealth, that’s usually the modality that they cover. So the other two [modalities], while effective for some things, are not as widespread for coverage as live video.
OM: [04:55] Right. So as someone who’s sort of been working in the state and federal policy for your entire career. I’m curious if you can sort of paint us an overarching picture of the trends that you saw telehealth adoption for the past few years before coronavirus, and then maybe talk about how that pace has sort of been accelerated by this pandemic.
MK: [05:20] So I’ve been doing telehealth policy for about ten years. So I would say it wasn’t really until the last five years where you saw telehealth really pickup. And that’s for a variety of reasons. Telehealth has been around for decades, but it wasn’t really ubiquitous throughout the health system or throughout the country. And part of that was that the technology was not there to do what people could imagine it could do. So it was only kind of more recently that the technology kind of caught up with that. So that was one reason why telehealth wasn’t as widespread pre-COVID.
Another reason is that while the technology finally kind caught up, the policies in place didn’t really catch up. So in general, technology evolves much more quickly than policy. So you have your policy probably trending about ten years behind what the technology could do. So you still have like these old limitations—you can only use telehealth to do “x” and get paid for it. Well, if you don’t have those policies in place and whether to allow somebody to use telehealth to do something and provide a way to pay for it, they’re not going to use it a lot. So you have, like, sort of like low usage. The last five years, the policy has been slowly, incrementally getting better. And that’s both on the state and a little bit on the federal level. Federal has been a little bit slower than what the states are doing.
So this is kind of what your landscape is like pre-COVID. It was getting better, but it was still going at a slow and steady rate. COVID-19 rolls around and it just suddenly explodes. I liken it to that unknown actor who suddenly has been cast to be the star of a new Marvel franchise. It’s like, nobody knew who you were before. You were slow and steady and probably doing good work. But nobody is thinking about you. And then suddenly Marvel’s makes you the new Iron Man or something.
So that’s kind of what happened with COVID, and with good reason, because it was so uniquely suited for this pandemic. To address what some of the concerns were, which was that you had people sheltering in place, and you still need to get them to care. You do that through telehealth. You can still minimize exposure for both the patient and the health care provider. Why you saw so many telehealth policy [changes] like temporary waivers or guidance was because those old policies were still in place that limited telehealth. That’s why CMS had to do so many changes because they hadn’t kept pace with what the technology could do. The policies were outdated. So both on the federal or state level, you saw so many changes. The states vary—there are some states that had to do less. And then there were other states that had not done as much with, and they had to do more.
OM: [08:28] So when you talk about sort of these sweeping policy changes that have happened as a result of COVID, can you just give some top-line examples of changes to Medicare, Medicaid, HIPAA that America’s been seeing?
MK: [08:43] A lot of the policies, like the Medicare and Medicaid policies and probably some commercial payers, they didn’t allow the patient to receive services at home. Well, that was kind of one of the major points during COVID, everybody was saying at home.
So that had to be changed—where the patient was located. Another thing that had to be changed was the type of provider providing services. A lot of Medicare and a lot of Medicaid programs limited what type of health care provider could provide a service via telehealth and get paid for it. Medicare has a very short list; it’s like about eight or nine providers that they allow. That had to be expanded because providers that weren’t on that list were some of your allied health professionals like OTs, PTs, and speech pathologists. They’re not on that list, so that needed to be expanded as well.
And also, types of services that are covered, too. So, again, a Medicare example, they are limited to very specific list of services and they go by that. I don’t know if your audience might be familiar, but how health care professionals usually bill is by a code for a specific service and as a definition of what type of services it is. It has a code number to it and that’s how they get paid. They go back to the payer who says, “you provided this service and we would pay you this amount”, because that’s associated with that code. So it thought that CMS says, “oh, we’ll pay for all services associated with treating a skin rash.” No, they don’t say that. They said we’ll pay for these specific codes. So Medicare definitely had like a specific list of some Medicaid programs, too. So they had to extend that because there were other services that they were hoping could be provided via telehealth to people who were sheltering in place.
OM: [10:56] And how do you think the policy changes have differed between people who are publicly insured versus people who are privately insured, when you have these private insurers doing voluntary changes to their policies?
MK: [11:10] It’s been a little more difficult to get a handle on what exactly all the private insurers are doing. So even even before COVID, it was difficult to understand what they were doing with their telehealth health policy. Part of that was because, unlike Medicare and Medicaid, they don’t necessarily make it public. I mean, I’ve seen health plans come out; commercial payers said, “oh, we’re going to cover telehealth services.” It’s like, well, what does that mean? Does that mean every service you cover, you can do it through telehealth? Is it this sort of like a narrow band of services? It hasn’t been clear what some of the payers are covering when they say cover telehealth. So it’s a little harder to judge how expensive their telehealth policy and coverage have been because simply they haven’t made all the details publicly accessible for us.
OM: [12:10] Yeah, it’s been sort of nebulous even for me, just trying to learn about the different changes that they made. So I think I’ve experienced that.
MK: [12:19] I’ll give you like a very firm example here. So, for example, Medicare has said you can use phone to deliver a service. It’s for these types of services and they’ll say very specific codes or something. But they also have a category which they call “virtual check-in services,” which is a quick check-in that Medicare doesn’t classify as telehealth. They classify it as a technology-enabled service. So that’s like a whole in the weeds type of discussion, but you can use phone to deliver that. So that’s what Medicare does when you’re using a phone to deliver services. They’ve said, “you can use these specific things to deliver services, you could deliver these virtual check-in services.” And that’s what makes phone a way of delivering a service. And the health care provider can get paid for it.
A health plan may also say, “we allow phone to be a way of delivery services too.” But they may mean, “we only mean those virtual check-in services”, and not necessarily like these other band of services that you would typically think of, like an office consultation or a mental health type of interaction, perhaps. So that’s that’s also one of the confusions there. Just like how extensive are those policies? And do they mean the same thing of what people may be thinking because they’ve seen the Medicare policies?
OM: [13:46] Yeah, I think that’s a really clarifying example. So in a recent interview, CMS Administrator Seema Verma said, “the genie is out of the bottle” in regard to telehealth. Do you think that a lot of these policy changes are here to stay?
MK: [14:02] I think some of them won’t be. Which ones? I’m not quite sure. I can kind of guess which ones I think probably have the best chance of sticking around. Other ones I think probably will not stick around. You had mentioned HIPAA earlier, some of the rollback on HIPAA. I don’t think those will stick around, for example.
OM: [14:21] Why’s that?
MK: [14:24] Well, for one thing, the rollback on HIPAA was essentially the Office of Civil Rights saying, “we’re not going to find you for a HIPAA violation.” I don’t think that’s going to stick around. Now, the question is, though, does HIPAA right now have something specific related to telehealth? So there’s no specific policy within HIPAA that focuses in on telehealth.
The question is, does that open up a discussion with policymakers say we need to update HIPAA that we have telehealth. But the fact that, you know, they gave this grace period of not fining people. I don’t think we’ll stick around because they’Il want people to go back to protecting health information, abiding by those rules they understood. Right now is an emergency period. But once the emergency is over, I just see that rolling back to what it was before. But the conversation may be open, they need to really updated HIPAA to include this technology that really wasn’t widely available before HIPAA. So again, policy trending a little bit behind technology.
But I do think some of the changes, some of the temporary waivers, will stick around. I’ve gotten questions both on the federal and state level, we’re discussing what to keep. And some of them probably have a better chance than others. For the federal ones, a lot of the barriers were actually statutory barriers. So it would require Congress to pass a bill and the president to sign it. But there are some things that CMS can do administratively and decide on their own to keep around. So those would be kind of like easier things to do if they wish to keep that policy around because they wouldn’t have to go through Congress. So those, I kind of rate as having a higher likelihood of sticking around.
OM: [16:25] One historical barrier to telehealth has been licensing restrictions, leading many states to join into interstate compacts. But, of course, there’s been the issuance of Section 1115 waivers, allowing many doctors who are licensed in one state to practice outside of their state. Do anticipate that these licensing regulations will stick around or change after America fully reopens?
MK: [16:53] I think the licensing issue will become a much more discussed topic than it was before COVID. It was kind of like one of the major barriers identified. It was talked about a lot. I think the discussion will be ratcheted up once we get past the immediate emergency and then you may actually hear policymakers more interested in doing something about it than they were before. You know, it was always a topic of discussion. Sometimes you had policymakers who were resistant. I’ll use California as an example. California is actually not a member of any licensure compact. So there’s just been sort of very strong resistance to joining them.
But I think probably that some of that resistance from policymakers, they have softened in discussing the licensing issue or even even had their interest increased. And the reason I say that is because I think more [people] during this pandemic have become aware that this is a significant issue. And I think part of it may be they’ve either had firsthand experience with it or somebody that know had firsthand experience with it.
I’ll give you an example. I got a policymaker who contacted me and said, “is this true? I have a colleague who’s college student daughter had to come home because the university is shut down.” She couldn’t access her student health provider who she was seeing before this all hit, because it’s a different state now. Why can’t that provider provide a service here in this state? Well, because there’s there would like no specific waiver to provide that service.
And that sparked an interest in that policymaker saying, “wait, you’re telling me this can’t happen because of this licensure issue?” This is from somebody who I know, and had not expressed an interest in the subject before. I think we’ll probably find, like a lot of policymakers who maybe have that firsthand experience or are hearing about from constituents or from friends, relatives, or their own staff, because it’s impacted so many people. Not only like college students, but maybe if somebody got stuck in a state and they can’t travel. I got another call just a few days ago from, like a national organization, saying, “somebody reached out to us. It’s a woman who had cystic fibrosis, who was in one state, but her doctors were in another state and the doctors couldn’t provide services.” I said, “I’m sorry, it’s a licensure issue.”
OM: [19:47] So obviously, there’s a pretty large disparity between the way that different states carry out telehealth and the policies that they have in place. Do you think there are any states that serve as a good example of [telehealth policies that] could lay groundwork for widespread adoption?
MK: [20:05] If you’re talking about their Medicaid policies, California is a good example. So ironically, before COVID, California had just updated and expanded for Medicaid telehealth policies. They had had they still had stuff to do during COVID to expand it. But they actually had less [to do] than what a lot of other states had to do. So California for Medicaid policies has really forward thinking types of policies on Medicaid.
For commercial payers, it depends on what type of statute they have in place. California is one of the states that updated. Then there are a couple other states that have one, you know, more explicit policies on what commercial payers are supposed to do. Hawaii, Minnesota, they’ve got pretty extensive commercial payer policies. So it kind of really depends on what you’re trying to do. But in general, those are kind of the states in those specific areas, like with Medicaid or the partial payer laws, doing what they need to do. Now, the tally up with the commercial payer law, it’s really important how they’ve written them. And it’s also really important how it’s carried out.
There could be some sort of ability for the health plans to interpret it a certain way. So the law would have to be written pretty clearly. And like what, the requiring of the health plan. Then also none of these laws in place actually have any type of punishment if a health plan doesn’t abide by. There’s a there’s never like listed a consequence. So we have encountered conversations with providers where they said, “I tried to do this with my health plan and the commercial plan has told me no.” It’s one or two things: how well was the law written in the first place? There may be a lot of flexibility for a health plan and how they interpret it. They may be able to legally not cover the service that you’re trying to offer via telehealth. And also, if they’re not abiding by what in the law, you’re going to have to make a complaint to whatever authority regulates them in the state and then see what happens. And that’s been kind of rare.
I’m not sure if I heard a lot of people making complaints . There was one of the Midwest states where for the first time, about a year ago, where we did hear of a state agency fine a health plan for not following the telehealth law. They did fine the plan and the plan said it was because [they] just didn’t get our system in place. The law had passed too recently for [them] to get it in place. But that was the first time I had heard of a state action enforcing a private payer.
OM: [23:43] Did you hear any other states bring it up after that or was it sort of an isolated incident?
MK: [23:49] It was isolated, as far as I know. I had not heard of any other states. And they fined it like $150,000 or something. The plan was like, “we’ll pay it. Sorry. We just didn’t get our systems up and running in time.”
OM: [24:07] So I did want to talk a little bit about anticipating problems that are coming out as a result of new policies or some fears that people have about rolling out telehealth. Telehealth providers can now waive patient deductibles and copayments during the emergency. Under normal circumstances, these actions would be interpreted as kickbacks. Some feel that maybe lowering these barriers could cause a wave of billing fraud to CMS. I’m wondering, do you think that that’s going to be a substantial problem? And if so, what can be done to kind of mitigate it?
MK: [24:53] Obviously, there is a concern that during this time when you remove the guardrails, you can just go wild or something, somebody’s going to go wild. And it’s understandable to have that concern. The odds are you’re going to have one bad apple, at least. So I can understand the concerns regarding that, but will that happen? I don’t know.
Part of it is that, historically, there hasn’t been a lot of fraud related to telehealth. I know in recent years there’s been some big news, of arresting 60 people related to telehealth fraud to Medicare. But a lot of that, it’s like that kind of what you see in a typical fraud cases. And it was sort of like, you were prescribing unnecessary prescriptions for people who didn’t even need them. You didn’t even realized you were doing that because you signed them on for whatever reasons. Well, that’s kind of what fraudsters were always doing. You just happened and have had a telehealth element. So it wasn’t just a telehealth thing, but it was something that people had been doing probably since Medicare program was available.
Are we going to see that? We’re human beings and the odds are you likely will have a bad actor. I would not be surprised if there were some [bad actors]. But I would say probably the majority are legitimate reasons for billing Medicare. They are providing services to people who need it, and they are doing everything correctly. One thing is that they would still need to bill properly in order to get paid for for telehealth. When we’re passed this pandemic, it will be interesting to see what the data is. I’m not going to say there’s not gonna be any fraud. Even with the guardrails in place, you’re still going to have some fraud. We’re human. And if somebody wants to do it, you’re going to find a way to do it. The best you can do is that [telehealth] does open it up so you can get the services to the people who need it, and that the provider will get paid for their efforts to provide services to those folks.
OM: [28:36] I just want to ask quickly about reimbursement rates for health care providers. It seems that there’s been some confusion about how health state Medicaids are going to do that. Maybe there’s been some uneven reimbursement rates: doctors not getting paid exactly what they anticipated they would be paid. Have you seen this as a major problem and are there ways to sort of more efficiently roll out these new rates?
MK: [29:23] So Medicare and Medicaid, for the most part, should still be the same rate as to the person. Where I think probably some of the problem has been is going back to our phone example, where I was talking about the virtual checking codes that came up. CMS and Medicare doesn’t consider it telehealth, but it uses telehealth technology or technology to provide the service. That’s gotten murky and confused in a lot of people’s minds.
So Medicare, what it does is it has essentially two buckets: the telehealth bucket, where they define the services provided via telehealth that they reimburse and have all their policies around. Then, they have another bucket of something that they call “technology-enable” or “communication-based services,” which use telehealth technologies, but they don’t call it telehealth.
This is because telehealth is considered a one-to-one replacement for in-person services. Whereas [sometimes] they have this technology to provide services, but don’t necessarily have a one-to-one match up. So those technology-enable services aren’t underneath the same restrictions as telehealth, though CMS has set up other restrictions. I think the two buckets have merged in a lot of people’s minds. They think telehealth [is the same as] technology-enabled services. It’s not treated that way by the program, though, in how you bill and the codes you use. With Medicaid, some of them have adopted those codes too and adopted that separation. But in some providers’ minds, they think it’s all telehealth.
The reason I’ve gone through that explanation is that some of those technology-enable services pay a lot less than what you would get for a telehealth-delivered service, because the telehealth-delivered services is paid the same amount as in-person.
Something I’ve heard specifically from doctors is that they say, “I used telehealth and I only got paid ten dollars.” I dig a little deeper, and they did a service over the phone and were told to bill a specific virtual check-in code, which does pay ten dollars. The provider though they were doing an office consultation [to be paid] ten dollars. No, you just coded it wrong, as a virtual check-in code.
OM: [32:54] Are there ways that doctors can get more familiarized with these billing codes? What channels would they go through to figure out the root of the problem?
MK: [33:10] Billing is a whole other world that’s very complicated. You could take courses and courses on how to bill Medicare, and then you add this other [telehealth] layer and it get even more complicated. Usually they have to send a question into the telehealth resource centers, which CCHP is one, and we try to sort through the problem. Medicare and Medicaid are usually very good about clarifying which codes to bill and if you fit into the definitions for one of those codes.
Commercial payers are a little more difficult. It’s difficult to get hands on their policies, from an outsider viewpoint. I would assume it’s easier for a provider in their network that can ask them for it. But it is a very difficult landscape to navigate. The biggest issue that I’m hearing from providers during this time is that [billing] is so complicated and [they] have a mix of Medicare, Medicaid, and commercial patients and how to bill for telehealth is different. It is extremely confusing.
And for a consumer to understand what they can do, it’s going to vary for them. The options where they can get information [about coverage] varies. They can ask their health plan what they cover. If they get insurance through their employer, they can talk with their HR department. The resources available to consumers at that specificity are extremely small. California is one of the few states with a consumer portal that provides telehealth information. They can type in their zip code and see the health plans that say they consider telehealth-delivered services, and then [be directed to] the health plan’s site. That varies because [consumers] are sent to the health plan’s site and the available information varies from plan to plan. But that is one of the few examples where states or the federal government [tries to give] more information to the consumer. The Department of Health and Human Services did put out a website with more information for educational information for patients using telehealth. And that was only available during COVID, so nothing was really available pre-COVID. CCHP tried to put out as much information for consumers [as possible], but that’s an area where the consumer relies more on the primary care provider to tell them about it.
OM: [37:45] If our listeners are interested in learning more about telehealth [generally], what sort of resources does CCHP recommend?
MK: [38:07] If they want to get into the policies, they can definitely come to the CCHP website. We track all the state Medicaid policies, the Medicare policies, the state legislation, and the policy changes of COVID. But that can be too dense for some people. [They can also go to] telehealthresourcecenter.org, where you can access all 14 telehealth resource centers and general information. Those two are you best places to start. Depending of the type of person you are [such as a provider, consumer, older person, or parent], there’s a lot of different organizations that are focused in on telehealth such as AARP and the School-Based Health Alliance. I would start with the telehealth resource centers and especially CCHP if you’re interested in the policy side. Feel free to reach out to a telehealth resource center [and ask for] good resources, then we’ll be able to narrow it down on your specific issue.
AV: Thanks for listening to this week’s episode on Centering on Coronavirus from The New Center. Please be sure to visit newcenter.org to sign up for our updates and stay tuned for another episode next week.