Telehealth Beyond COVID-19

Because of COVID-19, some restrictions on reimbursement, security, licensing, and prescribing have been relaxed (5–7) to promote rapid telehealth uptake in order to support physical distancing. For instance, the Centers for Medicare and Medicaid Services (CMS) have expanded reimbursement for telehealth services for the duration of the COVID-19 pandemic, and many private payers have followed suit (5). Support for reimbursement includes removing restrictions on the locations of the provider and the patient, expanding services, and ensuring payment parity. Expansion of services involves inclusion of different providers so that some health care workers, such as occupational and speech therapists, are now permitted to be reimbursed for services rendered via a telehealth modality. In addition, patients and providers previously needed to meet for face-to-face consultations in an official health care service facility to be eligible for reimbursement, but now both patient and provider are permitted to meet each other virtually in their homes. Services that are eligible for using telehealth modalities have expanded beyond general medical and behavioral health services and now also include physical, occupational, and speech therapies; home dialysis; and substance use disorder treatments. This expansion also includes nonvideo visits such as remote monitoring and virtual check-ins. Furthermore, telehealth visits via audio-only connection can be reimbursed at the same rate as for in-person face-to-face visits. As with face-to-face consultations, payment for telehealth services depends on the length and complexity of the visit.

Some other private payers and state Medicaid plans have followed suit to support telehealth services. At least 40 states have coverage parity for certain telehealth services, and some have payment parity (6). Many states have expanded telehealth coverage during the pandemic. Some states have participated in the Interstate Medical Licensure Compact to permit telehealth services across state lines (7), and others have expanded Medicaid coverage for substance use disorder treatment. In addition, states have expanded telehealth modalities and payment parity, and some states have allowed for prescriptions via telehealth without a previous in-person exam. Commercial payers vary in telehealth coverage. They have expanded payment and reduced requirements for reimbursement for telehealth consultations during the pandemic, including waiving requirements for previous in-person exams and restrictions on new patients and allowing audio-only telehealth encounters.

Because of COVID-19, the U.S. Drug Enforcement Administration (DEA) has relaxed the enforcement of rules for prescribing controlled substances via telehealth consultations (8). Until recently, the DEA required that controlled substances be issued via telehealth only after a previous in-person visit with the physician, a requirement that has been temporarily relaxed. Moreover, the DEA has indicated that health care providers do not have to register with the DEA in each state as long as they are registered in at least one state.

Telehealth services require a stable technical infrastructure. However, some areas of the United States do not have access to broadband high-speed Internet with stable connectivity (9). This lack of connectivity can result in poor audio and video quality, disconnection, and slowed information exchange. Moreover, some patients and families in such areas may not have access to technology at home to participate in telehealth. To expand reliable access to the Internet during the pandemic, the Federal Communications Commission now has an active grant program that supports health care providers. This program allows providers to expand their technical infrastructure to support core care during the COVID-19 pandemic (10). Funding will be available until the allocated funds are exhausted or the pandemic is over.

Health care providers must establish mechanisms to protect patient privacy when using telehealth services. Patient privacy is protected through HIPAA and through the Code of Federal Regulations (42 CFR Part 2) (11). HIPAA protects patient privacy and security generally, and Part 2 addresses more protections of the privacy of patients with a substance use disorder (12). Neither HIPAA nor 42 CFR Part 2 specifically addresses telehealth, and many organizations rely on telehealth vendors to address technical aspects of compliance. Because of the pandemic, providers needed to establish telehealth services quickly and may not have had the time to identify, select, and implement services with vendors whose technologies were compliant with HIPAA and Part 2. In response to the urgent need to establish services quickly, the Office of Civil Rights (OCR) issued a statement indicating that consumer-facing technologies that do not necessarily meet traditional security requirements, such as FaceTime and Skype, are permissible during the pandemic, as are use of smartphone apps and verbal consent (8).

In their efforts to promote physical distancing during the COVID-19 pandemic, agencies such as the CMS, DEA and OCR have revised rules governing reimbursement procedures, Internet connectivity and security, and prescriptions to enhance telehealth uptake. The agencies have stated that these changes are for the duration of the pandemic. It is not clear if all, some, or none of these changes will be retained after this public health emergency has ended.

Organizations must consider several factors when determining the future of their programs after the pandemic. As health care organizations review the telehealth programs they will provide after the COVID-19 pandemic, they need to consider questions across seven key domains associated with successful telehealth implementation and use. These domains are service selection, operational changes, technical infrastructure, staff engagement, patient outreach, financial considerations, and service evaluation and continuous improvement.

Policy changes in response to the COVID-19 pandemic have reduced barriers to telehealth uptake by expanding reimbursement, allowing use of additional technologies, providing support for technical infrastructure, and permitting prescribing for medication-assisted treatment via telehealth services. Each government agency has stated that these changes are in place just for the duration of the pandemic. It is unclear whether all, some, or none of the changes will be retained after the pandemic.

When looking to the future, organizations may need to revisit their telehealth strategies. Decision making should include what services to retain or expand and how to measure success, ensure financing, and engage patients and staff when telehealth technologies are used. Organizational leaders and clinical and administrative staff all have roles to play in providing telehealth services, and their input should be sought when determining the future of telehealth.