To: Senators Kristen Gillibrand and Charles Schumer
From: Matthew Lemieszewski, PA-S
Date: July 18, 2021
Re: Proposed federal action to expand access to and coverage of telemedicine

Statement of Issue:

According to The Annals of Family Medicine, 45% of physicians receive patients through physician referrals annually. However, many primary care providers are unaware as to whether the specialist is being utilized by the patient. From limited providers in rural areas to patients with limited mobility, there are many barriers to receiving in-person care. One of the largest challenges faced during the COVID-19 pandemic was finding safe and effective ways to treat patient’s without COVID conditions for their many illnesses and comorbidities without putting them at risk for catching the virus. In their efforts, twenty-two states enacted temporary orders to enhance private insurance coverage of telemedicine in 2020.

• According to the CDC, during the first quarter of 2020, the number of telehealth visits increased by 50%, compared with the same period in 2019, with a 154% increase in visits noted in surveillance week 13 in 2020, compared to the same period in 2019. During January-March 2020, most encounters were from patients seeking care for conditions other than COVID-19.
  
  
• Jefferson Health, the second largest health system in Philadelphia found that diverting patients from unnecessary Emergency Department visits through telehealth platforms saves providers $1,500 per patient encounter.
  
  
• Concerns over the liability of telemedicine providers extends to civil, penal, and disciplinary liability. Coupled with a lack of unified legal framework for telehealth care can lead to a discouragement of use.
  
  
• Socioeconomic factors such as employment and income may inhibit some individuals from using telemedicine due to costs if they are not available as a service in a federal program.

Policy Options:

• Modernize  payment policies while improving management by reimbursement parity between telemedicine and in-person services. Because there is a lack of a universal definition of virtual care delivered, there is also a lack of standardization in approaches to payment. Currently, Medicare does not pay for training or education, and limits payment to real-time audio or video encounters between providers the patient.
  
  
  • Advantages: Incentivizes providers to adopt telehealth into their practice which will lead to overall lower costs of care as patients will not see a provider in person for every ailment, saving money on unnecessary labs typically performed during face-to-face visits.  
    
    
  • Disadvantages: Because of the ability to extend the reach of those who can utilize telehealth services, this leads to a higher potential for overuse, which can take up time that providers could be spending with patients who actually do need care. Additionally, virtual visits require less clinical effort when compared to patients seen in person. As the number of patients grows significantly, this can lead to levels of burnout of providers which can also increase the chance of medical errors.

• Employ state level reciprocal licensing and credentialing allowing out-of-state physicians to render care. This would work with state Medicaid offices to expanding coverage for remote care services.
  • Advantages: Allows more accessibility and expedition of telehealth in rural and underserved communities by seeing a provider not in your area. Creates a unified system in line with the initial licensing process for physicians and mid-level providers.
    
    
  • Disadvantages: Putting providers at risk for lawsuits across state lines on the grounds that medical advice given may be negligent or cause injury. It is possible that a lawsuit in one state is not covered by the provider’s home state malpractice insurance.
    
    
• A partnership with the Federal Communications Commission to increase broadband access to underserved urban and rural areas. Working with the nation’s largest internet providers, providers can receive federal funds to increase their ability to deliver care electronically to the 23% of Americans who currently do not have a wired broadband connection.
  • Advantages: Enabling video and audio services to patients allows for quicker access to a provider while saving on time, transportation, and costs. Being able to see a provider to review exam results or conduct some parts of a physical exam, this gives patients the opportunity to speak privately with a provider when there may not be one accessible where they live. In situations that are deemed medical emergencies, the provider would be able to alert local 911 to get people the treatment that they need in person.
    
    
  • Disadvantages: The financial obligation of getting access to all Americans has been estimated around $80 billion by the FCC, these funds would have to be collected in a way that congress sees fit. Further, increasing access to the internet can lead to increased anxiety and decreased mental health as patients being to self-diagnose based on symptoms they put onto a medical website.
    
    

Policy Recommendations: According to the most recently available US Census, by 2030, all members of the baby boomer generation will be older than age 65. With the current size of this population, that will mean that one in every five US residents will be retirement age. Doximity, the nation’s largest physician network predicts that by 2023, as much as $106 billion of current US health care spending could be on virtual services. Due to these facts, it is imperative to fix the payment policies of the system before expanding it to individuals currently unable to access it. Working with elected officials to require reimbursement parity and waive cost sharing will not only incentive providers to adapt to the world of telemedicine but also ensure that our older generation will be able to continue to obtain the care that they need. Employing efforts to ensure more individuals can afford this care will in turn lead to less unnecessary trips to hospitals and private practices which will save time, money, and resources, all things of utmost value in the world of healthcare.

References:

• Doximity , 2020, 2020 State of Telemedicine Report: Examining Patient Perspectives and Physician Adoption of Telemedicine Since the COVID-19 Pandemic, c8y.doxcdn.com/image/upload/v1599769894/Press%20Blog/Research%20Reports/2020-state-telemedicine-report.pdf.
  
  
• Eron, Lawrence. “Telemedicine: The Future of Outpatient Therapy?” OUP Academic, Oxford University Press, 15 Sept. 2010, academic.oup.com/cid/article/51/Supplement_2/S224/383896?login=true.
  
  
• Jin, Michael X, et al. “Telemedicine: Current Impact on the Future.” Cureus, Cureus, 20 Aug. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7502422/.
  
  
• “Policy Changes during COVID-19.” US Department of Health and Human Services: Telehealth, telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/.
  
  
• Powell, Rhea E, et al. “Patient and Health System Experience With Implementation of an Enterprise-Wide Telehealth Scheduled Video Visit Program: Mixed-Methods Study.” JMIR Medical Informatics, JMIR Publications, 13 Feb. 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC5829457/.
  
  
• “Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic – United States, January–March 2020.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Oct. 2020, www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm.
  
  
• United States, Congress, Office of Strategic Planning and Policy Analysis, Paul De Sa. Improving the Nation’s Digital Infrastructure , 2017. www.fcc.gov/document/improving-nations-digital-infrastructure.