The novel coronavirus (nCV) pandemic represents an unprecedented challenge to our health care system. Yet as a physician (Bruggeman) and U.S. senator/physician (Cassidy), we know that it is often times of challenge that bring out the most innovation as our health care system adapts to changing conditions to ensure that patients receive the care that they need. nCV response is no different.
During the nCV crisis, our health care system is adapting to uncertain conditions by rapidly expanding the use of telehealth services. Screening and care of nCV patients is not the only area of expansion, treatment of medical conditions unrelated to nCV infection has also broadly embraced telehealth. Providers and patients have quickly adapted to broadly increased offering of telehealth services because of the new flexibilities in delivery made possible by the CMS waivers, private payor temporary benefits expansion, and legislative solutions.
As an example, the Department of Veterans Affairs health care system has seen a 1,000 percent increase in telehealth visits from the beginning of February through the first week of May.
Even more remarkably, reports show that use of telehealth among Medicare beneficiaries has increased by nearly 12,000 percent since the beginning of March.
Even in the midst of responding to nCV, we can – and should – be planning for what’s next for our health care system after the pandemic. Because once this pandemic passes, many of the flexibilities in telehealth that have resulted in unprecedented access for patients will go away, if the normal restrictions return.
For instance, rural patients’ access for telehealth services is limited because payment models are not attractive for urban providers. For providers in urban areas – where the majority practice – there has been little incentive to offer telehealth services since reimbursement will not cover their local, urban patients. These arbitrary rules cut off access not only to urban patients, but also to rural patients when providers are less likely to offer telehealth services to begin with.
Another barrier to access for rural patients has been prohibition of receiving telehealth services in their home. Under traditional Medicare rules, telehealth must be delivered to the rural patient at a medical facility. The problems with this are clear.
Barring coverage for receipt of telehealth services in the home often means that care is delayed or forgone altogether. The ability to receive telehealth services in the home bypasses access barriers due to lack of transportation, feeling too ill to travel, anxiety or stigma in seeking care at office visits, and risking exposure to nCV patients. Missed appointments contribute to unmanaged disease, higher health care costs, and worse-patient outcomes.
Expanding telehealth access to all patients – regardless of their geographic location and in their home – are important starting points for where we go from here.
It’s not only important where patients can access telehealth services, but the type of services that they have access to. Reports forecast a surge in mental health needs resulting from the pandemic, whether due to the effects of social isolation, dealing with the death of a loved one, or despair from months of unemployment. Access to telehealth can help respond to these needs.
During the pandemic, CMS has enabled Medicare reimbursement for group therapy provided through telehealth. While group meetings may sometimes be best conducted in person, the ability to deliver via telehealth, when appropriate, is another important flexibility. For example, some patients prefer receiving behavioral treatment inconspicuously from the comfort of their own home and as a result will be more likely to attend a group session via telehealth.
The growing shortage of behavioral health providers, compounded by rising rates of mental illness, means only a small proportion of people are actually receiving the care that is needed. For this reason, telehealth expansion for mental health services should be a top priority.
Telehealth simultaneously benefits both patients and providers. For patients, access to care is quicker, more convenient, and avoids potential for exposure to patients with nCV infection. For providers, telehealth delivery increases satisfaction through greater flexibility in where they treat patients, lowered no-show rates, and more direct access to patients, all of which can counter the skyrocketing rates of provider burnout.
In the Medicare program, we need to make permanent the ability to reimburse telehealth care for both rural and urban settings and for treatment at home. The list of mental health services which can be reimbursed via telehealth should be expanded to address gaps in access and better meet patients’ needs. This will require cooperation between lawmakers and regulators, as some changes can be achieved through administrative action, while others will require legislation.
The actions that CMS takes often sets the precedent that private payors follow in covered services. That is why in a letter that Sen. Tina Smith and I (Cassidy) sent along with 36 other senators we asked CMS to provide guidance to private plans on how to provide advance notice to their enrollees regarding future changes to coverage of telehealth services. Private plans should also be encouraged to maintain the telehealth flexibilities that they have provided through the full duration of the pandemic – not curtailed prematurely or cut off abruptly – and to extend some flexibilities permanently, like enabling patients and providers to perform and receive telehealth services from the comfort of their homes.
For too long the U.S. health care system has lagged behind the demands and needs of patients in the 21st century. The number of patients with smart phones and laptops are growing by the year, and increasingly patients are expecting digital access to their providers. nCV response has pushed innovation on our outdated payment systems at least temporarily, but we must act to ensure that these changes remain in place to continue benefiting patients once the pandemic has passed.