AMA Delegates Examine COVID-19 Telehealth Change

Physicians discussed the best way to advocate for new flexibilities in telemedicine granted to patients and clinicians due to the COVID-19 pandemic, during the American Medical Association virtual Special Meeting of its House of Delegates.

Whether in response to mandatory quarantines or patients’ concern for their own risk of transmitting the virus, many more patients are choosing telemedicine, and the Centers for Medicare & Medicaid Services (CMS) has encouraged that shift in care by relaxing many of the restrictions that typically limit patient access to telemedicine. (See “Telehealth Changes a First Step“)

At the meeting on Saturday, during committee discussions, AMA delegates introduced two separate resolutions focused on this issue.

The New York delegation called for continued coverage of “the full spectrum of technologies” available during the pandemic; urged that public and private payers appropriately account for the “time and complexity” of care; and suggested that current emergency regulations, which have improved access and reimbursement, be made permanent.

Robert Goldberg, DO, a New York delegate and the author of the policy recommendation, sought to amend his original resolution from calling for insurers to provide coverage for telemedicine “with any physician licensed and registered to practice in the United States” to “any physician permitted to practice under state law.”

Goldberg called for the more narrow language in order to discourage insurers from hiring physician assistants and nurse practitioners across the country in place of physicians.

A separate resolution sponsored by Virginia, West Virginia, and a handful of other states asked the AMA to advocate for “widespread adoption of telehealth” among physicians and physician-led teams after the pandemic ends and urge CMS, health insurers, and federal and state governments to use “uniform, clear regulations” and equitable coverage and reimbursement for “physician-led telehealth.”

Clifford Deal III, MD, a delegate from Virginia, speaking on behalf of the resolution’s author, highlighted the portions of the proposed policy calling for AMA to advocate for telehealth’s availability across a range of payers and regulatory agencies “with a focus on equitable access to telehealth for under-resourced populations.”

More than two dozen AMA members from a range of specialties, including psychiatry, dermatology, surgery, and obstetrics-gynecology, spoke in support of the resolutions.

One member, Don Casey Jr., MD, a delegate for the American College of Medical Quality, called for standardizing the language of the policy proposals, noting that “telehealth” and “telemedicine” have distinct definitions and should not be used interchangeably.

Barbara Hummel, MD, a delegate from Wisconsin, speaking on her own behalf, stressed the importance of recognizing seniors’ limitations in using telehealth. “Many of my elderly patients don’t even own a smartphone,” Hummel said, adding that in the promotion of telemedicine, she worries that her patients will be left behind.

In addition, she said, some insurance companies won’t provide payment for the primary care doctors of these patients. “They have their own panel [of clinicians] and they won’t pay for anything else, and my patients won’t talk to these people because they don’t know them,” she said.

Hummel said she therefore supports the New York amendment that seeks to limit care to physicians in a particular state.

Louise Andrew, MD, JD, a delegate for the Senior Physicians Section, supported both resolutions, adding that telemedicine is particularly beneficial to her patients with mobility issues and those who are at risk or under-resourced, including elderly patients.

Telemedicine also benefits those physicians who may have an increased vulnerability to communicable diseases, Andrew noted.

She echoed Goldberg’s concern for ensuring consideration of “scope creep” by non-physician clinicians in any policy recommendation.

Michael Kitchell, MD, an Iowa delegate, who spoke on behalf of the North Central Medical Conference, in support of one portion the New York resolution, had reservations about other parts: Rural Americans have a 23% higher mortality rate across all ethnic and racial groups mainly because payment disparities limit access to care, Kitchell explained.

For that reason, he said, he felt it important that the policy stress payment parity among all originating sites and ensure there isn’t any “geographic devaluation” of payment.

Kitchell recommended the portion of the New York resolution that relates to “payment parity” be referred to the committee.

Matthew Gold, MD, a delegate for the Organized Medical Staff Section, speaking on his own behalf, also spoke against the concept of payment parity. As a cognitive neurologist, he said, “parity is not good.” Concepts like “time and complexity” are difficult to measure, he noted.

“I think you have to watch … what you’re asking for, and the fact is that quality is already immeasurable except for hypertension and diabetes. We’ve got to do better on a quality measurement so that we can actually get paid for telehealth,” Gold said.

Anna Heffron, a delegate from Wisconsin, speaking on behalf of the Medical Student Section (MSS), supported both resolutions and proposed an amendment to the Virginia policy recommendation, which called on the AMA to advocate for equitable access to telehealth for at-risk patients and communities, asking that it also advocate for “supporting increased funding and planning for telehealth infrastructure such as broadband and internet-connected devices for both physician practices and patients.”

Heffron said that working in rural parts of the country, she has seen the impact of connectivity on healthcare. “At least once a week … we can see patients who have doctors’ visits interrupted or have to be rescheduled, due to the fact that their internet connection is unreliable and cannot support telehealth capabilities,” she said.

Several delegates spoke in support of the MSS amendment, including Dave Cundiff, MD, a delegate for the American Association of Public Health Physicians, who lives in rural Washington. “As a rural physician, I see every day that without affordable broadband access there is no telehealth,” he said.

Mary Carpenter, MD, a member of the Council on Legislation, which reviews all the policies introduced to this particular committee and makes recommendations to the AMA, noted that an alternate policy combining the substance of both the telemedicine and telehealth resolutions would be submitted to the committee.

She said the AMA has actively promoted the “equitable adoption” of telehealth by CMS and other payers, including through its support for the Telehealth Modernization Act of 2020, which would revise the Social Security Act to remove originating site and other geographic restrictions for telehealth. The AMA has also called on CMS to make permanent statutory changes allowing the delivery of telehealth to patients, regardless of their location.

The alternate policy recommendation (no. 203) was included in a reference committee report released Sunday evening.