Telehealth Struggles to Find Permanent Footing After Rapid Growth During Pandemic

Telehealth Struggles to Find Permanent Footing After Rapid Growth During Pandemic

Evolving Standards of Care
Aug 27, 2021
Beth Fand Incollingo
The ILCN is aware that the situation with telehealth differs across regions and that lack of access to technology is a huge obstacle. We would love to hear from IASLC members around the globe about your experiences. Please email us at [email protected]
Woman sits at a computer speaking with a doctor

To Kyle Zebley, the growth of telehealth stands out as the “silver lining” of the COVID-19 pandemic.

“There were 10 years’ worth of advances for telehealth in a period of a couple of weeks during the early days of the pandemic. Right now, our number-one policy priority is to make sure that we lock in [those] gains,” said Mr. Zebley, director of public policy for the American Telemedicine Association.

Due to pandemic-related waivers of federal and state regulations, telehealth has been employed both more frequently and across more areas of care—trends that have had reverberations in the lung cancer community as patients report that the technology has improved their quality of life.

While experts across all sectors of healthcare agree that telehealth is here to stay, that’s where their accord ends. Mr. Zebley believes that all Americans should have access to telehealth and supports allowing physicians to use it at their discretion, but others want stricter limits. Just as divergent are opinions about how telehealth should be codified and paid for.

For now, that leaves physicians practicing in a gray area.

“Patients and doctors want reliable healthcare and a reduction in uncertainty, and it's not useful for a provider or a patient to know that [telehealth] will get paid for the next 2 months or the next 6 months or until the end of the public health emergency,” said Judd Hollander, MD, associate dean for strategic health initiatives at Philadelphia’s Sidney Kimmel Medical College at Thomas Jefferson University. “In an ideal world, I would be able to get rid of some of my brick-and-mortar fees and replace them with really good telemedicine platforms. But right now, I can't do either.”

The Promise of Telehealth

Regardless, telehealth’s growth in the United States has been striking. At a high point in March 2020, national private-insurance claims for remote visits had seen a 1-year jump of 4,347%, having risen from 0.17% to 7.52% of all medical claims,1 FAIR Health reported. The proportion is lower now, but still represents a significant jump since before the pandemic.

Telehealth has long been used to connect medical experts with patients in rural communities. Going forward, it will certainly be practiced more widely, but ensuring its cost-effectiveness will require determining the most beneficial applications of telehealth and restricting it to those uses, said Ateev Mehrotra, MD, MPH, associate professor of healthcare policy at Harvard Medical School.

So far, he said, telehealth has proved appropriate for treating substance abuse problems, stroke, and especially mental illness.2 According to America’s Health Insurance Plans, it is also well-suited for triaging those who are sick or injured; facilitating provider-to-provider consultations; and talking with patients about social needs, such as housing or food.

Finally, Dr. Mehrotra noted, telehealth works well for supporting continuity of care, allowing doctors to continue managing patients with chronic conditions who, for example, go to college out of state or spend winters in Florida.

Virtual visits are also important to patients with rare lung cancers, who may want second opinions from the “few specialists across the country” without having to travel, added Kristen Santiago, senior director of public policy initiatives for LUNGevity Foundation.

A recent meta-analysis3 highlighted telehealth’s ability to improve quality of life for patients with lung cancer. The review evaluated the remote care of 635 individuals with the disease across eight studies conducted between 2014 and 2020. It found that quality of life was higher in patients who received these interventions—particularly telephone-based visits—compared with usual care alone (standard mean difference [SMD] 0.96, 95% CI[0.29-1.63]; I2 = 91%). Furthermore, those in the telehealth group were found to have lower anxiety (SMD −0.44, 95% CI[−0.66 to −0.23; I2 = 3%) and depression scores (SMD −0.48, 95% CI[−0.91 to −0.05]; I2 = 66%) compared with the usual-care group.

Removing the obstacle of distance and the ability of doctors to give immediate feedback were among the reasons the intervention proved helpful, the authors suggested. Strikingly, despite ongoing debate about whether audio-only telehealth should continue to be covered, the authors said the study’s elderly population responded better to phone versus video calls.

Identifying Challenges

Without legislative intervention, however, remote visits of any kind will likely become less accessible.

During the pandemic, the U.S. government accommodated telehealth by temporarily waiving section 1834 of the Social Security Act, among other rules. “Most notably, this means that you [no longer] have to be in a defined rural geographic area [or] physically in a provider's office in order to have reimbursable telehealth care through the Medicare program,” Mr. Zebley said.

In addition, most private payors have agreed to cover telehealth during the ongoing public health emergency associated with COVID-19, Dr. Mehrotra said.

But that hasn’t addressed what may be the largest obstacles to telehealth: state regulations regarding the licensing and disciplining of doctors, the sale and governing of private health insurance, and Medicaid policy, Mr. Zebley said.

While many states have temporarily allowed doctors licensed elsewhere to practice telehealth within their borders,4 that patchwork of rules is inconsistent and not expected to remain in place indefinitely.

“Permanent waiver of these flexibilities at the state level varies widely, of course, and there have been over 600 bills introduced since the beginning of the year,” Mr. Zebley said.

The licensing standards have created a precarious situation for doctors who engage in telehealth.

“My understanding is that it’s lower risk to see a patient you know who just had surgery and who lives in a different state, where if you don't see that patient either in person or via telemedicine you're effectively abandoning a patient you operated on,” Dr. Hollander said. “On the other hand, it would be exceedingly high-risk to put a billboard up in a state you're not licensed in to get new patients you have no relationship with. In the middle is where you're balancing the strict legal interpretation of that state's rules with your obligation to your own patients.”

Of course, this creates practical problems: For instance, Dr. Mehrotra asked, what if a doctor is licensed in a patient’s home state, but the patient is at a friend’s house across the border at the time of a virtual visit?

“I'm sure that patients lie all the time and tell me they're in Pennsylvania,” Dr. Hollander added.

These restrictions often prevent patients with lung cancer from securing remote appointments for second opinions, Ms. Santiago said.

“The question is: What's considered practicing medicine versus giving an opinion or having a conversation?” she said. “We've heard from patients who've been rejected because that specialist is not licensed in the state where they live, whereas, pre–COVID-19, if they drove across the country to meet with that doctor, [the visit would be allowed]. It’s a really antiquated law, and it's in place to keep business within states, so that [doctors] don't lose business [to others] outside of their state borders.”

The licensing issues affect reimbursement, too. According to Dr. Hollander, many institutions are leery of billing private insurers for remote visits conducted by a doctor who isn’t licensed in the patient’s state of residence, leaving the physicians to conduct the appointments for free.

Even when licensing laws are followed, Dr. Hollander believes, payors will be generally reluctant to reimburse doctors for telehealth visits until standards are set compelling them to comply, “because for every minute they delay paying for it, they put profits in their shareholders’ pockets.”

On the contrary, Mr. Zebley argued, health insurers who are members of the American Telemedicine Association have led the way in offering telehealth coverage.

For its part, America’s Health Insurance Plans (AHIP) is advocating for policies that encourage the growth of telehealth. But for cost-effectiveness, the organization stipulates, remote care should be delivered through value-based and hybrid models and billed at lower rates than on-site visits—suggestions Dr. Mehrotra supports.2

Regulating Telehealth

To begin the journey toward a solution, Congress acted in December 20205 to permanently expand telehealth coverage for mental health conditions under Medicare, and some legislators support extending existing waivers for several years to allow time for study of the value of telehealth’s broader applications, Dr. Mehrotra said.

His own recommendation is for the permanent passage of all federal pandemic-related telehealth waivers, which would generally be accomplished through the Telehealth Modernization Act,6 coupled with a mandate allowing Medicare beneficiaries to receive virtual care from physicians anywhere, regardless of where the doctors are licensed. That, in turn, would create pressure on states to provide the same benefits for patients with other forms of insurance, he said.

Meanwhile, about 6,500 physicians have tried another tack: joining the Interstate Medical Licensure Compact, which grants the right to practice in as many as 30 states but charges $700 to join and also passes along each state’s licensing fee. Congress could increase the deal’s effectiveness by encouraging its expansion to all states along with the lowering of costs, Dr. Mehrotra said. On the other hand, the Nurse Licensure Compact uses a reciprocal model: When adopted by a state, the nurses licensed there are automatically allowed to practice in the other participating states. Smaller compacts have also sprung up in specific regions around the country, Mr. Zebley said.

Dr. Hollander suggested yet another strategy: that licensed physicians be allowed to practice telehealth in any state unless they have been disciplined or settled malpractice suits there.

If out-of-state competition is a concern, he said, that benefit should be limited to doctors who are able to access a patient’s electronic medical record and share notes about the visit with the individual’s primary-care physician, thus supporting continuity of care.

According to Ms. Santiago, telehealth’s restrictions should exempt oncologists so that they can offer virtual second opinions across borders, and LUNGevity is working with state attorneys general to make that happen. To underscore this need, she is asking patients and doctors to share their anecdotes about telehealth visits denied due to state licensing laws by emailing her at [email protected].

With so many factors in the mix, the path toward a simple, navigable telehealth system, at least in the US, looks murky and complex. Nevertheless, experts see a clear future for the practice.

“I believe everybody in the world knows that, 10 years from now, telemedicine is going to be the way a ton of medicine is delivered,” Dr. Hollander said, “and nobody doubts it.