Tuesday, June 27, 2023

Trending in Telehealth is a new series from the McDermott digital health team in which we highlight state legislative and regulatory developments that impact the healthcare providers, telehealth and digital health companies, pharmacists, and technology companies that deliver and facilitate the delivery of virtual care.

Trending in the past week:

• Telehealth pilot programs
• Mental health

A CLOSER LOOK

Finalized Legislation & Rulemaking

• Connecticut enacted HB 6768, which permits physicians, advanced practice registered nurses and physician assistants to certify a qualifying patient’s use of medical marijuana and provide follow-up care using telehealth if they comply with other statutory certification and recordkeeping requirements.
• Florida enacted HB 5101, which requires each school district to implement a school-based mental health assistance program that provides behavioral health services in-person and supplemented by telehealth.
• Florida enacted SB 2500, which provides additional funding for telehealth services under the Minority Maternity Care program.
• Illinois enacted SB 1298, amending the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities to permit medical and emergency telehealth services for persons with intellectual and developmental disabilities.
• Louisiana enacted SB 186, adopting the Occupational Therapy Licensure Compact.
• Louisiana enacted SB 66, which amends the state insurance code by replacing the term “telemedicine” with “telehealth,” for consistency throughout the code. The amendment does not require a provider to have an in-person examination with the patient prior to using telehealth but does require that a referral be made to an in-state healthcare provider or in-state follow-up care be arranged if necessary. The amendment also permits the use of interactive audio without video if, after access and review of the patient’s medical records, the healthcare provider determines that the provider is able to meet the same standard of care as if the services were provided in-person.
• Louisiana enacted HB 41, which requires health plans to provide equivalent coverage and payments for telehealth occupational therapy services as for in-person services, unless the plan and the provider agree otherwise.
• Louisiana enacted HB 181, which allows coroners to use telehealth when conducting an examination for an emergency mental health commitment.
• Texas enacted HB 2727, which amends the requirements for the home telemonitoring program under Medicaid, including reimbursement requirements.
• Texas enacted HB 617, which establishes a pilot project to provide emergency medical services instruction and emergency prehospital care instruction through a telemedicine medical service or telehealth service provided by regional trauma resource centers to healthcare providers in rural trauma facilities and emergency medical services providers in rural areas.
• Texas enacted SB 1146, increasing access to telehealth services for inmates. The law requires the Department of Criminal Justice, in conjunction with The University of Texas Medical Branch at Galveston and the Texas Tech University Health Sciences Center, to establish procedures to expand access to telemedicine medical services, telehealth services and onsite medical care for inmates, including onsite mobile care units that provide diagnostic imaging, physical therapy and other appropriate mobile health services.

Legislation & Rulemaking Activity in Proposal Phase

Highlights:

• Maine progressed LD 757 in the second chamber to expand telemonitoring in the MaineCare program. The rules would allow a provider to offer telemonitoring services if medically necessary given the patient’s health status, and would allow providers to determine the frequency of telemonitoring services to achieve care plan goals for the patient.
• Rhode Island progressed SB 965 in the second chamber. The bill would amend the Telemedicine Coverage Act and define a patient-provider relationship as a relationship where the healthcare professional agrees to undertake diagnosis and treatment of the patient and the patient agrees to be treated.
• Rhode Island progressed HB 6489 in the second chamber to establish telepractice standards for audiology and speech language therapy and pathology professionals.

Why it matters:

• States continue to progress and pass legislation establishing telehealth pilot programs across multiple departments. As noted in past posts, pilot programs are important steps to determine the best uses of telehealth and increase access to healthcare in vulnerable populations.
• States continue to progress and pass legislation expanding the use of telehealth and telemedicine for mental health.

The post Trending in Telehealth: June 13 – 21, 2023 appeared first on mTelehealth.

Time is running out for Congress to take action on pending legislation dealing with issues that would help primary care across the United States.

Six physician groups representing 590,000 doctors across the country sent a joint letter again urging congressional leaders to vote – soon – for bills relating to Medicare reimbursements, prior authorizations, children’s health insurance coverage, mental health, telehealth, and aid for resident physicians in primary care.

Time is of the essence, said the Dec. 2 letter by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association.

“As we approach the end of the 117th Congress, we urge Congress to act on the important items described below to ensure our patients have access to quality, affordable, and accessible health care,” the letter said.

The issues

The bill: House Resolution (HR) 8800, the Supporting Medicare Providers Act of 2022

The issue: The Medicare Physician Fee Schedule (MFPS)

Physicians, health care administrators, and their supporters hope to avert a 4.42% cut to physician payments scheduled in 2023. Medicare reimbursement involves “a very complex set of budgetary rules and systemic flaws” in the MFPS “that, unless addressed in a comprehensive way, will continue to plague physicians for years to come.” Payment rates are not keeping up with inflation and are not sustainable for physicians to cover basic expenses such as staff salaries, rent, or new technology.

The bill: HR 3173, the Improving Seniors’ Timely Access to Care Act

The issue: The bill would standardize and streamline the prior authorization approval process in the Medicare Advantage program. The bill has passed in the House of Representatives and has at least 43 bipartisan cosponsors in the Senate. Proponents argue the bill would improve health care for seniors by speeding up access, while removing paperwork headaches for physicians and staff.

The issue: Medicaid’s Children’s Health Insurance Program (CHIP)

Medicaid and CHIP cover 42% of all births in the country. When the COVID-19 pandemic public health emergency (PHE) ends, so will coverage for an estimated 5 million children, along with postpartum females. Enacting 12 months of continuous eligibility for them “will ensure that children and new mothers can rely on coverage and will save states the administrative cost associated with churn,” or those who will lose insurance when the PHE ends.

The issue: Mental health care

A comprehensive legislative package must address growing mental health issues and substance use disorder (SUD). Four potential solutions:

• Promote behavioral health services in primary care.
• Strengthen the behavioral health workforce with money for graduate medical education for psychiatric residencies and for loan repayment programs.
• Enhance promotion, prevention, and early intervention with more money for community health and mental health centers and schools.
• Enforce mental health/SUD parity laws.

The issue: Telehealth

Congress should extend Medicare telehealth flexibilities at least to Dec. 31, 2024, including coverage for audio-only services, to ensure access for beneficiaries and financial stability and regulatory clarity for physicians. Medicare telehealth access will continue for 151 days after the end of the COVID-19 PHE, but that limited extension and ambiguity about the end of the PHE leaves physicians and patients in a state of uncertainty.

The issue: Teaching Health Center Graduate Medical Education (THCGME)

Residents who train through THCGME are more likely to focus on primary care and more likely to remain in underserved or rural communities. The program is successful in tackling physician maldistribution, but the medical groups “have grave concerns for the financial stability of programs for the upcoming year.” Flat funding could put programs at risk of closure, the medical groups said.

Recipients

The letter was sent to House Speaker Nancy Pelosi, House Minority Leader Kevin McCarthy, Senate Majority Leader Chuck Schumer, Senate Minority Leader Mitch McConnell; Rep. Frank Pallone and Rep. Cathy McMorris Rodgers of the House Energy & Commerce Committee; Rep. Richie Neal and Rep. Kevin Brady of the House Ways & Means Committee; Sen. Ron Wyden and Sen. Mike Crapo of the Senate Finance Committee; and Sen. Patty Murray and Sen. Richard Burr of the Senate Health, Education, Labor, & Pensions Committee.

The post U.S. health care will suffer if lawmakers don’t act by end of 2022 appeared first on mTelehealth.

A study published in JAMA Network Open found that despite an overall decline in visit rates throughout the COVID-19 pandemic, high telehealth availability led to better care engagement among Medicaid beneficiaries with mental health conditions treated within federally qualified health centers (FQHCs).

Various studies have shown telehealth has expanded and improved care for mental health patients and those with low incomes during the COVID-19 pandemic.

For example, a June report from FAIR Health noted that mental health conditions were the most common telehealth diagnoses at the national level between 2020 and 2022. 

Dig Deeper

• Louisiana Lawmakers Expand Access to Mental Health Services via Telehealth
• Telehealth Access to Mental Health Specialists Can Be a ‘Game-Changer’ in the ED
• Telehealth Services Expand Veteran Access to Mental Healthcare

Also, according to the new JAMA Network Open study, only 6 percent of Massachusetts FQHCs used telehealth to provide live mental health services in 2019. However, in 2020, all Massachusetts FQHCs delivered mental health services through telehealth.

Despite this growth, some uncertainties remain, mainly surrounding the correlation between telehealth availability and visit rates among mental health patients enrolled in Medicaid.

To assess the correlation, researchers conducted a cohort study that included patients between the ages of 18 and 64 who were Medicaid beneficiaries with a mental health diagnosis. All study participants were also attributed to Community Care Cooperative and had at least one FQHC visit within 18 months prior to each month studied. This included at least one visit that took place before the expansion of telehealth during the pandemic. The main source of data was the 2019-2021 Electronic Data Warehouse.

Using data from 11,267 patients, researchers found that overall visit rates in FQHCs declined during the pandemic. However, despite this decline, higher availability of telehealth was associated with higher visit rates compared to lower telehealth availability. Results were similar after reviewing data from patients with various diagnoses.

Based on this information, researchers concluded that the high availability of telehealth within FQHCs is linked to higher levels of care engagement among Medicaid beneficiaries with mental health diagnoses. 

However, the study’s limitations included the use of only one year of post-telehealth expansion data, potential errors in data reporting, and uncertainties regarding applicability outside of Massachusetts.

But the study’s findings align with prior research on telehealth’s impact on mental healthcare access and use.

A report from October indicated that patients see various benefits in using telehealth for primary and mental healthcare. The report detailed a survey of over 1,000 patients, which showed that telehealth use fell following the return to in-person healthcare.

But, among the healthcare consumers open to continuing telehealth use, most preferred virtual visits for primary care (55 percent) and mental healthcare (45 percent).

The report also found that telehealth satisfaction was high, with many survey respondents indicating that their telehealth experience was positive.

Earlier this year, clinicians spoke with mHealthIntelligence about how telehealth can help close pediatric mental healthcare gaps. They detailed strategies and key considerations for expanding telehealth access.

One prominent strategy for expanding pediatric mental healthcare access is to bolster the behavioral health workforce, the clinicians said. Resources such as telepsychiatry can help extend the workforce to meet the increased demand for child psychiatrists during the COVID-19 pandemic.

The post Telehealth Availability at FQHCs Linked to Engagement in Mental Healthcare appeared first on mTelehealth.

The American Telemedicine Association (ATA) and ATA Action co-led a letter, along with the American Psychiatric Association (APA) and the American Association of Child and Adolescent Psychiatry (AACAP), urging the Biden administration and the DEA to take action to ensure patients now remotely accessing clinically appropriate care do not have their access to care interrupted when the public health emergency ends – and before relevant regulations are finalized.

“With the unified voice of the undersigned organizations, all leaders in healthcare delivery, we are hopeful that the administration and the DEA will take notice – and most importantly, take action – to ensure patients are not left out in the cold,” said Kyle Zebley, senior vice president, public policy, the ATA, and executive director, ATA Action, in a statement. “Patients and providers need both a long-term solution, hopefully in the promulgation of the Special Registration for Telemedicine rules originally put forward by the DEA years ago, as well as a short-term solution until those rules are finalized.

“We believe it is equally important for Congress to maintain the current flexibilities on remote prescribing, to ensure there are no interruptions in the continuity of care. It’s for this reason that we included so many Congressional leaders on the letter, to remind them that our most vulnerable patients may face the telehealth cliff if swift actions are not taken to remove outdated restrictions to telehealth and virtual care services.”

The post American Telemedicine Association advocates on behalf of remote mental health appeared first on mTelehealth.

Following President Joe Biden’s State of the Union Address on Tuesday, Health and Human Services (HHS) Secretary Xavier Becerra kicked off the National Tour to Strengthen Mental Health in an effort to hear directly from Americans across the country about the behavioral health challenges they’re facing and engage with local elected officials and leaders to strengthen the mental health and crisis care system in our communities.

“The pandemic has not only taken a physical toll on all of us, but also brought on greater behavioral health challenges for everyone,” said Secretary Becerra. “From small towns to big cities, I’ll be traveling nationwide with members of my leadership team to meet with people who have been hit particularly hard, and partnering with local leaders to find ways to save lives in our communities. The Biden-Harris Administration will continue to deliver on our promise to build back better – and healthier.”

As President Biden launches a whole-of-government strategy to transform mental health services for all Americans, Secretary Becerra is leading HHS to address the mental health challenges that have been exacerbated by the COVID-19 pandemic, including substance use, youth mental health, and suicide. Building on work that agencies and offices across the Department have already been doing, Secretary Becerra and HHS leaders will hit the road in a concerted effort to deliver on the Biden-Harris Administration’s priorities to tackle these challenges.

Over the next few months, Secretary Becerra will make announcements on new initiatives and various resources provided by HHS, such as increasing the number of behavioral health professionals and community and behavioral health support workers in underserved and under-resourced communities, expanding pediatric mental health care access through telehealth services, and the transition to 988: America’s Suicide and Crisis Lifeline. Through meetings with partners, local leaders, and elected officials across the country, the Secretary will highlight the work HHS is doing and also take time to listen and gather ideas about ways to partner with states and communities to strengthen mental health services, and what more the Department can do.

The term “behavioral health” refers to the promotion of mental health, resilience and wellbeing; the treatment of mental and substance use disorders; and the support of those who experience and/or are in recovery from these conditions, along with their families and communities.

Provisional data from the Centers for Disease Control and Prevention (CDC)’s National Center for Health Statistics indicate that there were an estimated 100,306 drug overdose deaths in the United States during the 12-month period ending in April 2021, an increase of 28.5 percent from the 78,056 deaths during the same period the year before. To combat this crisis, Secretary Becerra announced the release of the new HHS Overdose Prevention Strategy, designed to increase access to the full range of care and services for individuals who use substances that cause overdose, and their families.

Even before the COVID-19 pandemic, mental health challenges were common, with 1 in 5 adults experiencing a mental illness in any given year. Mental health challenges were the leading cause of disability and poor life outcomes in young people, with up to 1 in 5 children ages 3 to 17 in the United States having a mental, emotional, developmental, or behavioral disorder.

Additionally, from 2009 to 2019, the share of high school students who reported persistent feelings of sadness or hopelessness increased by 40 percent, to more than 1 in 3 students. The share of high school students who seriously considered attempting suicide also increased during this period, by 36 percent. The pandemic only exacerbated youth mental health challenges. In December 2021, the U.S. Surgeon General Dr. Vivek Murthy issued a new Surgeon General’s Advisory to highlight the urgent need to address the nation’s youth mental health crisis.

“Our country faced a mental health pandemic long before the COVID-19 pandemic began, and it was exacerbated by the traumatic effects of the past two years. That’s why, last December, I issued a Surgeon General’s Advisory on protecting youth mental health – because it will take policy, institutional, and individual changes alike to reframe and address this crisis with the urgency it deserves,” said Surgeon General Vivek Murthy. “I am grateful to Secretary Becerra and the Biden-Harris Administration for recognizing this, and for their commitment to work with communities across the country to strengthen and protect mental health.”

According to the CDC, in 2020, suicide was among the top 5 leading causes of death for people ages 10-64. Suicide was the second leading cause of death for people ages 10-14 and 25-34. Some groups have higher suicide rates than others. Among the highest rates are American Indian/Alaska Native and White populations, veterans, people who live in rural areas, and young adults who identify as lesbian, gay, or bisexual.

The National Tour to Strengthen Mental Health will also promote health equity and prioritize hearing from diverse voices. The Secretary will travel to traditionally underserved communities and hold conversations in spaces and places that are under-resourced. As the Secretary leads the Administration’s efforts to ensure equitable access to health care, HHS will continue working across the Department and in partnership with other agencies to close behavioral health disparities and invest in comprehensive treatment, early intervention, prevention, and recovery support services for all Americans.

The Secretary also intends to bring with him a message of hope – because in the face of startling statistics, there are prevention strategies that work and stories of resilience that should be shared. For example, providing 24/7, free and confidential support to people in crisis works – numerous studies have shown that the existing SAMHSA-funded National Suicide Prevention Lifeline helps thousands of people overcome crisis situations every day. The transition to 988 in July will make it more accessible.

The post National Tour to Strengthen Mental Health appeared first on mTelehealth.

Appropriate application of telehealth could make health care delivery more efficient, explains Dr Mike Hoaglin.

As a currently practicing physician with plenty of experience working in the emergency department, I’m no stranger to advocating for patients’ access to care within complex and inefficient systems. Barriers to that care range from shortage of in-network supply of providers to the patient’s own social determinants of health struggles to make and keep a follow-up appointment. Outpatients with mental and behavioral health issues are especially vulnerable to falling through the cracks in the health care system but have incredible promise for improved outcomes through telehealth.

The costly mental health crisis in America likely touches every family in some way. Mental illness affects 1 in 5 adults and half of those are not receiving treatment. In addition to possible toxic central nervous system effects of the SARS-CoV-2 virus itself, the COVID-19 pandemic took its toll on mental health due to the changes to regular lifestyle, unintended consequences of social distancing, quarantine, working from home, not being able to work from home, or not being able to work at all. Confirming what providers already knew anecdotally across the care continuum, a meta-analysis revealed at least a 25% increase in cases of depression and anxiety in 2020 compared with 2019.

During the March-August 2020 peak pandemic period, 40% of mental health and 11% of non–mental health visits were performed via telehealth. While non–mental health visits have dropped down to 5% telehealth, mental health holds strong at 36%, according to a March 2022 study.

Telehealth Allows Us to Do More for Patients With Less

More clinician interaction, less waiting. The patient and provider have important live, face-to-face video calls (often referred to as “synchronous” visits), similar to visits in person, but the patient is not leaving home or work, arranging childcare, driving and finding parking, or waiting in a brick and mortar waiting room. The patient’s time is respected and used more efficiently. The provider and health care system enjoy more efficiencies as well; according to a study, the no-show rate of telehealth visits during the pandemic was 7.5%. This is lower than the in-office visit no-show rate of 36.1% and a prepandemic in-office no-show rate of 29.8%.

The patient-provider interactions may continue between live, synchronous visits. While elaborate digital therapeutic programs exist, fundamental aspects include secure text messaging and symptom surveys. These typically nonurgent interactions may be referred to as “asynchronous” or “store and forward” visits, as the communications are not live. Symptom surveys (sometimes referred to as a form of “remote patient monitoring”) may include widely accepted instruments such as the PHQ9 or GAD7 used to periodically monitor symptom levels of depression and anxiety, respectively, between live visits. Armed with these asynchronous check-ins, clinicians can adjust medications, follow up on safety concerns, or otherwise initiate timely intervention rather than waiting for the next scheduled live visit. These online tools keep patients engaged, reducing risk and improving outcomes. Additionally, they allow practices to leverage clinician time in a more efficient manner.

More choices, less stigma. Telehealth allows providers to meet patients where they are in life. Patients may be at home, traveling for business, or unable to go outside due to their anxiety. During the pandemic, most of US health care enjoyed a relaxation of medical licensing laws, revealing the promise of nationwide telehealth. In many cases, doctors could care for patients in any state. Patients living in doctor-shortage areas could finally get an appointment, and patients with cancer could get second opinions at multiple renowned cancer centers in the same day from the comfort of their home. Many mental health patients were getting the help they needed after years of feeling stigmatized and going untreated, as accessing care privately from a smart phone seemed more familiar and accessible.

Telehealth Still Has Its Limitations

Not every patient is appropriate for telehealth. Ongoing triage remains an important part of patients getting the care that they need, and some patients simply do not prefer telehealth. Patients with severe issues may be out of scope for telehealth and require a higher level of care.

Furthermore, medical licensing has once again become a barrier, as all but 10 states have returned to prepandemic licensing requirements across state lines.

Telehealth Needs More Financial Support From Payers and Legislation

We’ve been practicing some crude form of telehealth for decades if you include doctor-patient email and phone communications. We are just now accepting the codification of it as a legitimate medical encounter. While synchronous coverage has been widely accepted as reimbursable, payers would do well to expand coverage to better include reimbursement for asynchronous care. They stand to benefit from providers intervening in a timely fashion and patients likely achieving remission earlier. We also need state support to again reduce barriers to receiving care across state lines.

Regardless of the specialty, evidence shows that appropriate application of telehealth to the appropriate patient makes health care delivery more efficient.

The post Contributor: Telehealth Is Efficient at Dealing With Mental Health Needs appeared first on mTelehealth.

In its early days, telehealth was under-researched, underfunded, and underutilized by a general public largely unaware of the vast potential benefits. Today, following a period of rapid evolution fueled by the COVID-19 pandemic, telehealth may offer a solution to one of the most pressing problems facing our nation’s youth: mental health crises.  

As of 2019, one in three high school students had experienced persistent feelings of sadness or hopelessness, a 40 percent increase since 2009. Despite these substantial increases, experts believe the trend is only getting worse. In December of 2021, U.S. Surgeon General Dr. Vivek Murthy issued an official advisory to highlight the urgency of addressing the nation’s youth mental health crisis, stating: 

“Mental health challenges in children, adolescents, and young adults are real and widespread. Even before the pandemic, an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide—and rates have increased over the past decade … the COVID-19 pandemic further altered their experiences at home, school, and in the community, and the effect on their mental health has been devastating. The future well-being of our country depends on how we support and invest in the next generation. Especially in this moment, as we work to protect the health of Americans in the face of a new variant, we also need to focus on how we can emerge stronger on the other side. This advisory shows us how we can all work together to step up for our children during this dual crisis.” 

The experts at the California Telehealth Research Center (CTRC) believe that school-based health centers (SBHCs) can play a significant role to address mental health crises in adolescent school-aged children.  

What Is A School-Based Health Center? 

School-based health centers are clinics that exist to ensure our youth have equal and equitable access to care. SBHCs employ several different models ranging from clinics with full-time medical and mental health staff to part-time clinics that offer a limited set of health services. Some SBHCs serve only students while others serve the entire community. The highly customizable nature of these clinics allows health professionals to better fill the gaps in equitable access to care.  

California’s School-Based Health Centers 

Of California’s 293 school-based health centers, 39% are in high schools, 21% are in elementary schools, 10% are in middle schools, and 25% are school-linked through the use of mobile medical vans. Many of these SBHCs serve the state’s most vulnerable children. For example, on campuses with SBHCs, about 70% of students receive free or reduced-price meals. Most of California’s SBHCs are located in low-income schools with student populations that experience higher rates of violent injury, poor nutrition, physical inactivity, substance abuse, and sexually risky behaviors.     

SBHCs offer high-risk adolescents services that have the potential to save their lives, given the impacts of childhood risk factors on higher rates of diabetes, heart disease, cancer, and other chronic illnesses in adulthood. In addition, these services can help high-risk adolescents overcome obstacles to academic success.    

Mental Health Of School-Aged Children: The Statistics       

As of 2019, approximately one in six youth reported making a suicide plan in the past year, a 44 percent increase since 2009. With suicide now among the top five causes of death among children ages 12-19, action to remedy this crisis is urgently needed. 

California’s Numbers 

According to data from Kidsdata.org, among California’s young people aged 5-19 there were over 37,000 hospital discharges for mental health issues; 12,719 for children ages 5-14; and 25,068 for teens ages 15-19 in 2020 alone. 

7 Reasons Why Supports for Adolescent Mental Health are Important 

• Most mental health disorders emerge before age 24, and the prevalence of such disorders is on the rise, affecting as many as one in five U.S. children and youth each year.  

• Suicide is the second leading cause of death among youth ages 10-24.  
• Treatment of mental illness is costly and accounts for the largest share of health care spending for children and youth in the U.S. 
• Most young people who need mental health treatment do not receive it, placing them at increased risk for negative outcomes throughout their lifetimes.  
• Anxiety disorders are the most commonly-diagnosed mental health conditions among youth, affecting an estimated 32% of U.S. adolescents.  
• Depression-related feelings also are common, with 37% of high school students nationwide in 2019 estimated to have had persistent feelings of sadness or hopelessness in the previous year, up from 26% in 2009.  
• Youth with anxiety, depression, or other mental health disorders are more likely to exhibit suicidal behavior, drop out of school, use alcohol or drugs, and engage in unsafe sexual activity, in addition to experiencing greater difficulties in school and with relationships 

The post Benefits Of Using Telehealth In Schools To Address The Adolescent Mental Health Crisis appeared first on mTelehealth.

1. What is telehealth?
   The Health Resources and Services Administration (HRSA) of the U.S.
   Department of Health and Human Services (HHS) defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and
   professional health-related education, and public health and health
   administration. Technologies include videoconferencing, the internet, storeand-forward imaging, streaming media, and landline and wireless
   communications. Telehealth services may be provided, for example, through audio, text messaging, or video communication technology, including videoconferencing software. For purposes of reimbursement, certain payors, including Medicare and Medicaid, may impose restrictions on the types of technologies that can be used.1 Those restrictions do not limit the scope of the HIPAA Notification
   of Enforcement Discretion regarding COVID-19 and remote telehealth
   communications.
2. What entities are included and excluded under the Notification of
   Enforcement Discretion regarding COVID-19 and remote telehealth
   communications?
   The Notification of Enforcement Discretion issued by the HHS Office for Civil Rights (OCR) applies to all health care providers that are covered by HIPAA and provide telehealth services during the emergency. A health insurance company that pays for telehealth services is not covered by the Notification of Enforcement Discretion. Under the Health Insurance Portability and Accountability Act (HIPAA), a “health care provider” is a provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in
   the normal course of business. Health care providers include, for example, physicians, nurses, clinics, hospitals, home health aides, therapists, other mental health professionals, dentists, pharmacists, laboratories, and any other person or entity that provides health care. A “health care provider” is a covered entity under HIPAA if it transmits any health information in electronic form in connection with a transaction for which the Secretary has adopted a standard (e.g., billing insurance electronically). See 45 CFR 160.103 (definitions of health care provider, health care, and covered entity). By contrast, a health insurance company that merely pays for telehealth services would not be covered by the Notification of Enforcement Discretion because it is not engaged in the provision of health care.
3. What patients can a covered health care provider treat under the
   Notification of Enforcement Discretion regarding COVID-19 and
   remote telehealth communications and does it include Medicare and
   Medicaid patients?
   This Notification applies to all HIPAA-covered health care providers, with no limitation on the patients they serve with telehealth, including those patients that receive Medicare or Medicaid benefits, and those that do not. Information specifically about telehealth and Medicare is available at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-healthcare-provider-fact-sheet and https://edit.cms.gov/files/document/medicaretelehealth-frequently-asked-questions-faqs-31720.pdf.
4. Which parts of the HIPAA Rules are included in the Notification of
   Enforcement Discretion regarding COVID-19 and remote telehealth
   communications?
   Covered health care providers will not be subject to penalties for violations of the HIPAA Privacy, Security, and Breach Notification Rules that occur in the good faith provision of telehealth during the COVID-19 nationwide public health emergency. This Notification does not affect the application of the HIPAA Rules to other areas of health care outside of telehealth during the emergency.
5. Does the Notification of Enforcement Discretion regarding COVID19 and remote telehealth communications apply to violations of 42
   CFR Part 2, the HHS regulation that protects the confidentiality of
   substance use disorder patient records?
   No, the Notification addresses the enforcement only of the HIPAA Rules. The Substance Abuse and Mental Health Services Administration (SAMHSA) has issued similar guidance on COVID-19 and 42 CFR Part 2, which is available at: https://www.samhsa.gov/sites/default/files/covid-19-42-cfr-part-2-guidance-03192020.pdf.
6. When does the Notification of Enforcement Discretion regarding
   COVID-19 and remote telehealth communications expire?
   The Notification of Enforcement Discretion does not have an expiration date. OCR will issue a notice to the public when it is no longer exercising its enforcement discretion based upon the latest facts and circumstances.
7. Where can health care providers conduct telehealth?
   OCR expects health care providers will ordinarily conduct telehealth in
   private settings, such as a doctor in a clinic or office connecting to a patient who is at home or at another clinic. Providers should always use private locations and patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances. If telehealth cannot be provided in a private setting, covered health care providers should continue to implement reasonable HIPAA safeguards to limit incidental uses or disclosures of protected health information (PHI). Such reasonable precautions could include using lowered voices, not using speakerphone, or recommending that the patient move to a reasonable distance from others when discussing PHI.
8. What telehealth services are covered by the Notification of
   Enforcement Discretion regarding COVID-19 and remote telehealth
   communications?
   All services that a covered health care provider, in their professional
   judgement, believes can be provided through telehealth in the given
   circumstances of the current emergency are covered by this Notification.
   This includes diagnosis or treatment of COVID-19 related conditions, such as taking a patient’s temperature or other vitals remotely, and diagnosis or treatment of non-COVID-19 related conditions, such as review of physical therapy practices, mental health counseling, or adjustment of prescriptions, among many others.
9. What may constitute bad faith in the provision of telehealth by a
   covered health care provider, which would not be covered by the
   Notification of Enforcement Discretion regarding COVID-19 and
   remote telehealth communications?
   OCR would consider all facts and circumstances when determining whether a health care provider’s use of telehealth services is provided in good faith and thereby covered by the Notice. Some examples of what OCR may consider a bad faith provision of telehealth services that is not covered by this Notice include:
    Conduct or furtherance of a criminal act, such as fraud, identity theft,
   and intentional invasion of privacy;
    Further uses or disclosures of patient data transmitted during a
   telehealth communication that are prohibited by the HIPAA Privacy
   Rule (e.g., sale of the data, or use of the data for marketing without
   authorization);
    Violations of state licensing laws or professional ethical standards that
   result in disciplinary actions related to the treatment offered or
   provided via telehealth (i.e., based on documented findings of a health
   care licensing or professional ethics board); or
    Use of public-facing remote communication products, such as TikTok,
   Facebook Live, Twitch, or a public chat room, which OCR has identified
   in the Notification as unacceptable forms of remote communication for
   telehealth because they are designed to be open to the public or allow
   wide or indiscriminate access to the communication.
10. What is a “non-public facing” remote communication product?
    A “non-public facing” remote communication product is one that, as a
    default, allows only the intended parties to participate in the communication. Non-public facing remote communication products would include, for example, platforms such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Whatsapp video chat, Zoom, or Skype. Such products also would include commonly used texting applications such as Signal, Jabber, Facebook Messenger, Google Hangouts, Whatsapp, or iMessage. Typically, these platforms employ end-to-end encryption, which allows only an individual and the person with whom the individual is communicating to see what is transmitted. The platforms also support individual user accounts, logins, and passcodes to help limit access and verify participants. In addition, participants are able to assert some degree of control over particular capabilities, such as choosing to record or not record the communication or to mute or turn off the video or audio signal at any point. In contrast, public-facing products such as TikTok, Facebook Live, Twitch, or a public chat room are not acceptable forms of remote communication for telehealth because they are designed to be open to the public or allow wide
    or indiscriminate access to the communication. For example, a provider
    that uses Facebook Live, Twitch, or a public chat room are not acceptable forms of remote communication for telehealth because they are designed to be open to the public or allow wide or indiscriminate access to the communication. For example, a provide that uses Facebook Live to stream a presentation made available to all its patients about the risks of COVID-19 would not be considered reasonably private provision of telehealth services. A provider that chooses to host such a public-facing presentation would not be covered by the Notification and should not identify patients or offer individualized patient advice in such a livestream.
11. If a covered health care provider uses telehealth services during
    the COVID-19 outbreak and electronic protected health information
    is intercepted during transmission, will OCR impose a penalty on the
    provider for violating the HIPAA Security Rule?
    No. OCR will exercise its enforcement discretion and will not pursue
    otherwise applicable penalties for breaches that result from the good faith provision of telehealth services during the COVID-19 nationwide public health emergency. OCR would consider all facts and circumstances when determining what constitutes a good faith provision of telehealth services. For example, if a provider follows the terms of the Notification and any applicable OCR guidance (such as this and other FAQs on COVID-19 and HIPAA), it will not face HIPAA penalties if it experiences a hack that exposes protected health information from a telehealth session. OCR believes that many current and commonly available remote electronic communication products include security features to protect ePHI transmitted between health care providers and patients. In addition, video communication vendors familiar with the requirements of the Security Rule often include stronger security capabilities to prevent data interception and provide assurances they will protect ePHI by signing a HIPAA business associate agreement (BAA). Providers seeking to use video communication products are encouraged to use such vendors, but will not be penalized for using less secure products in their effort to provide the most timely and accessible care possible to patients during the Public Health Emergency. Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable
    all available encryption and privacy modes when using such applications. OCR does not endorse the use of or the security capabilities of any particular communications product.

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The grants are part of a two-year program launched by HHS’ Substance Abuse and Mental Health Services Administration (SAMHSA) to help states and Tribal organizations use telehealth and other resource to tackle the opioid abuse crisis.

Federal officials are issuing roughly $1.5 billion to healthcare providers and other organizations to help them use telehealth and other tools to combat the opioid abuse crisis.

In the first year of the two-year, $3 billion State Opioid Response (SOR) and Tribal Opioid Response (TOR) grant programs, the money is being dispensed to state and Tribal agencies through the Health and Human Service Department’s Substance Abuse and Mental Health Services Administration (SAMHSA).

The funds go to a wide variety of evidence-based programs – included medication-assisted treatment (MAT) therapy and “innovative telehealth strategies” – designed to improve access to substance abuse treatment, mental health treatment and community-based support services.

“Programs such as these are instrumental because they facilitate greater access to evidence-based treatment,” Elinore F. McCance-Katz, MD, PhD, HHS’ assistant secretary for mental health and substance use, said in a press release. “Now, more than ever, this access to treatment for those with substance use disorders is especially critical.”

The grants continue a long-standing effort to tackle a growing problem that surfaced well before the onset of the coronavirus pandemic. And with COVID-19 hindering care providers in treating patients in person, many are turning to telehealth and mHealth platforms and tools.

“The COVID-19 pandemic hasn’t put a pause on our country’s opioid crisis,” HHS Secretary Alex Azar said in the press release. “We’re committed to a science-based approach for fighting the opioid crisis, focusing these State and Tribal Opioid Response grants on providing the gold standard for treatment: medication-assisted treatment with appropriate psychosocial services and community supports.”

Congress is looking to help out as well. In July, Senators Rob Portman (R-OH) and Sheldon Whitehouse (D-RI) introduced the Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act, which would make permanent certain emergency actions passed during the coronavirus pandemic to boost telehealth access for substance use disorder (SUD) treatment.

“The COVID-19 pandemic has affected every aspect of our lives and the increase in overdoses we’re seeing only increases the need for additional flexibility to help those suffering from addiction,” Portman said in a press release. “The roll out of telehealth waivers has both helped patients maintain access to care safely at home and increased access to care for those that didn’t otherwise have access to in-person treatment. As we move forward and look to life beyond this pandemic, we must make sure that the advances to care and access that telehealth is currently providing is not lost and that’s exactly what this bill will do.”

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Eight in ten large employers see virtual care and telehealth solutions as playing a significant role in healthcare delivery.

Employers are emphasizing virtual care and telehealth in their healthcare benefit and care delivery strategies during the coronavirus pandemic, a recent survey by the Business Group on Health revealed.

The organization conducted an online survey of 122 large employers who cover over 9 million lives.

“COVID-19 had a significant impact on employers’ perspectives on health, helping to strengthen the link between health care strategy and workforce strategy,” the report found. “It also affected planning for 2021.”

As companies manage the pandemic’s unpredictable influence over the work environment—particularly the high uncertainty around healthcare costs and budgeting—many employers have not changed their strategic priorities but, rather, have increased their focus and efforts.

“Many employers haven’t necessarily changed their strategic priorities. If anything, they’ve doubled-down and have been heightened related to their strategic priorities,” Ellen Kelsay, president and chief executive officer of Business Group on Health, told HealthPayerIntelligence and other media outlets on a press call.

Virtual care and mental health were two of the major priorities on which employers doubled-down their efforts, Kelsay shared.

For the third year in a row, implementing more care virtual care solutions is the top priority for employers.

However, unlike the past three years, this year the pandemic tested employers’ virtual care capabilities and forced them to adjust to digital healthcare solutions faster than anticipated.

Whereas barely more than half of large employers believed in virtual care’s influential presence for the future of healthcare delivery (52 percent) in 2018, now eight in ten large employers agree that virtual care will have a significant role in healthcare delivery.

Critically, this rising percentage indicated a long-term view of virtual care usage.

“There’s certainly no doubt that virtual care is here to stay,” Kelsay confirmed. “We’ve already seen significant traction in the virtual landscape for the past several years, and coronavirus has done nothing but accelerate that. We’ve seen an explosion of investment and resourcing from employers related to deploying more virtual solutions to their workforce.”

As a result, over three-quarters of employers (76 percent) are expanding virtual care solutions and 71 percent are accelerating telehealth and virtual care offerings. Almost seven in ten employers waived telehealth costs due to the pandemic and five percent already did not charge employees for telehealth services.

Naturally, some employers were able to build on existing virtual care offerings and others were new to the virtual care space when they adjusted to the coronavirus restrictions. But just because an employer already had a virtual care platform does not mean employees were engaging with it.

Seventy-eight percent of employers saw increases in virtual care utilization. Telehealth utilization also soared. Blue Cross Blue Shield Tennessee has reported that its telehealth claims hit 50-times their normal amount by May 2020.

Certain conditions are seeing higher telehealth usage than usual. From 2019 to 2023, employers expect musculoskeletal care management in particular will see the largest growth in virtual care services.

One issue that remains unsettled is reimbursement parity.

“We believe that employers should have the flexibility to design that based on what they think is appropriate for their plans,” Kelsay said in the press call.

“We want to be careful that virtual does not overlay additional costs onto an already challenging healthcare cost infrastructure. So making sure that these virtual models are deployed in a value based arrangement is going to be really important.”

Virtual care and telehealth are also helping employers tackle their second highest priority: mental healthcare.

Expanding low to no-cost virtual care is the top way that employers are planning to provide mental health access for 2021, with 54 percent intending to offer zero or low-cost virtual telemental health counseling to employees.

In contrast, exactly half of that number are expecting to give employees access to zero to low-cost on-site mental health counselors (27 percent).

In tandem with these strategies, employers intend to work with their health plan to expand mental health networks (45 percent) and cover out-of-network mental health and substance use disorder (17 percent) in 2021.

As employers continue to grow their virtual care offerings during the coronavirus pandemic, partnerships with payers could play into their decision-making process.

Employers have already shown a willingness to collaborate with their health plans in response to the crisis. Over sixty percent of employers said that they would partner with their payer when moving employees back to the office space, a recent Optum survey revealed.

Payers have been responding to employers’ concentrated attention on virtual care by adapting health plans. For example, Oscar Health now offers free virtual care and telehealth to eligible members.

Alignment Healthcare intends to start a virtual plan that serves Medicare Advantage members and five markets, pending regulatory approval in 2021. The plan would offer concierge-style care and services and incentivizes members to turn to virtual care solutions when appropriate for their treatment.

That being said, the Business Group on Health survey found that fewer employers reported that they were looking to payers and other healthcare partners for direction as they strategize around certain priorities, specifically delivery reform.

Whereas in 2019, 41 percent of employers said that they would defer to health plans and pharmacy benefits managers on how to adjust their delivery models, about half that percentage reported taking that approach in 2020.

Instead, a growing number of employers (24 percent) are taking the steering wheel on delivery reform and using virtual care and digital solutions to bypass the traditional delivery system altogether. Another thirty percent are combining this strategy with efforts to pursue alternative payment models and care delivery strategies independently.

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