By Noam N. Levey, Kaiser Health News
As the covid crisis wanes and life approaches normal across the U.S., health industry leaders and many patient advocates are pushing Congress and the Biden administration to preserve the pandemic-fueled expansion of telehealth that has transformed how millions of Americans see the doctor.
The broad effort reaches across the nation's diverse health care system, bringing together consumer groups with health insurers, state Medicaid officials, physician organizations and telehealth vendors.
And it represents an emerging consensus that many services that once required an office visit can be provided easily and safely — and often more effectively — through a video chat, a phone call or even an email.
“We've seen that telehealth is an extraordinary tool," said David Holmberg, chief executive of Pittsburgh-based Highmark, a multistate insurer that also operates a major medical system. “It's convenient for the patient, and it's convenient for the doctor. … Now we need to make it sustainable and enduring."
Last fall, a coalition of leading patient groups — including the American Heart Association, the Arthritis Foundation, Susan G. Komen and the advocacy arm of the American Cancer Society — hailed the expansion of telehealth, noting the technology “can and should be used to increase patient access to care."
But the widespread embrace of telemedicine — arguably the most significant health care shift wrought by the pandemic — is not without skeptics. Even supporters acknowledge the need for safeguards to prevent fraud, preserve quality and ensure that the digital health revolution doesn't leave behind low-income patients and communities of color with less access to technology — or leave some with only virtual options in place of real physicians.
Some worry that telehealth, like previous medical innovations, may become another billing tool that simply drives up costs, a fear exacerbated by the hundreds of millions of dollars flowing into the burgeoning digital health industry.
Companies offering remote urgent care, virtual primary care and new wearable technologies to monitor patient health are exploding, with the annual global telehealth market expected to top $300 billion by 2026, up nearly fivefold from 2019, according to research company PitchBook.
“I don't think there's any debate that there is a value in better access, but if this is just a one-off service that adds another billing option without fitting into patients' regular care, I don't know if it will do much for patients' health," said Tom Banning, head of the Texas Academy of Family Physicians.
Perhaps the most contentious issue facing politicians, insurers and hospitals is how much a telehealth visit is worth in a system that is already breaking the bank.
While Medicare and other insurers fueled the explosion of telehealth over the past year by paying the same rates as for in-person visits, many are expected to push for lower prices when the federally designated public health crisis ends. At the same time, physicians and hospitals are looking to maintain income.
“Payers are unlikely to give providers carte blanche," said Dr. Hoangmai Pham, a former senior medical official at health insurance giant Anthem. But Pham noted insurers could reward physicians and hospitals that take greater responsibility for their patients' overall health with higher rates for telehealth. “There's an opportunity here," she said.
For now, tens of millions of Americans have gotten used to meeting their doctor on a laptop or smartphone, and pressure is building on the federal and state governments to loosen rules to preserve virtual visits after the health crisis ends.
“I don't want to go back," said Suzy Brantley, a 67-year-old Texan who works at an accounting firm outside Dallas.
Brantley has been going to the same medical practice for more than 15 years. “I love them there," she said. But when the practice closed its doors last spring, requiring virtual visits, Brantley found she enjoyed the more convenient way to do routine business like refill a prescription.
“You don't have to leave work to go to the doctor," she said. “I can just step into the break room for a few minutes and use my phone. … I love it."
She's far from alone. In a nationwide poll last year, 8 in 10 Americans who had used telehealth said they “liked it" or “loved it." Nearly the same share said they were likely to continue using it after the pandemic, according to the survey by the Harris Poll.
Just a year ago, telehealth — or telemedicine, as it's also called — was largely a curiosity. Patient and physician wariness and strict rules about how doctors could bill had squelched widespread use.
Fearing fraud and overuse, the federal government tightly restricted the kind of video and audio visits that could be billed to Medicare, limiting use mainly to rural areas and to visits in which a doctor was in an office or hospital, rather than working remotely.
“There was a fear that if there was the slightest opening in the Medicare payment system, people would find a way to abuse it," said Sean Cavanaugh, who oversaw Medicare during the Obama administration.
That changed suddenly in spring 2020 as pandemic lockdowns shuttered physician offices. Almost overnight, doctors were forced to pivot to virtual care to maintain contact with patients and keep money flowing.The Trump administration moved quickly to facilitate the shift. The Medicare agency dramatically expanded the kind of services that could be provided virtually. Officials added 140 telehealth services to the list of what Medicare would pay for during the pandemic, including emergency visits, eye exams, speech and hearing therapy, and nursing home care.
Critically, Medicare raised fees for virtual visits to match those for in-office exams, a move followed by state Medicaid programs and many commercial insurers.
The surge was explosive. While fewer than 1% of primary care visits in Medicare occurred virtually in January 2020, by April nearly half did, according to data compiled by the Medicare Payment Advisory Commission.
At UnitedHealth Group, the nation's largest health insurer, the number of covered telehealth visits increased nearly thirtyfold, rising from 1.2 million visits in 2019 to 34 million last year. Other insurers reported as much as an eightyfold increase.
“Very quickly, it became clear that we could deliver very good care to our patients via televisit," said Dr. Manish Naik, chief medical information officer at Austin Regional Clinic in central Texas.
The medical group not only helped its primary care physicians pivot to telehealth, but it also built a virtual urgent care system that allows patients to connect by video with on-call doctors 24 hours a day, a model used by large medical systems such as Kaiser Permanente.
Other systems are moving beyond televisits to expand use of remote monitoring tools in people's homes that track vital signs of patients with chronic illnesses such as diabetes.
Perhaps nowhere has telehealth proved more transformational than in mental health services and treatment for patients addicted to drugs.
“Telehealth has been a godsend," said Ellen Bemis, chief executive of AMHC, a network of behavioral health clinics in rural northern Maine. Bemis said the clinics are already seeing patients adhere better to their medications as they remain in better contact virtually.
“I hope we never go back," she said.
In Alaska, health officials feel the same way. “What we've seen through covid was amazing," said state Medicaid director Albert Wall, noting a major decline in patients missing appointments.
Whether these changes endure depends largely on Congress and the Biden administration, which hasn't indicated whether it will make permanent the looser telehealth rules rolled out last year. The rules will sunset when the public health emergency ends, likely at the end of this year.
The uncertainty is fueling an urgent effort by physicians, hospitals, patient advocates and others to persuade government officials not to reimpose the strict limitations.
Democrats and Republicans in Congress have introduced bills to cement the changes. In statehouses, advocates for expanding telehealth have introduced more than 650 bills, according to the Alliance for Connected Care, a telehealth lobbying coalition.
“We've seen the potential of telehealth," said Dr. Christopher Crow, chief executive of Texas-based Catalyst Health Network, which helps primary care physicians manage their practices. “Now, we have to make sure we realize it before everyone starts shifting back to the exam rooms."
Major physician groups are pushing to maintain equal reimbursement for telehealth and in-person visits.
Dr. Susan Bailey, president of the American Medical Association, said Medicare should continue to allow patients to receive virtual care in their homes and in all areas of the country, not just rural areas.
The association is also pushing for Medicare to keep reimbursing doctors for consulting with patients by phone, a move Bailey said would ensure that patients without broadband internet service aren't left behind.
The push for more billable services has raised concerns about fraud, especially as physicians and hospitals develop more efficient systems to see patients remotely. “Overuse is absolutely a concern," said Dr. Von Nguyen, chief medical officer at Blue Cross Blue Shield of North Carolina. “Once these systems are in place, I suspect, the risk will be greater."
Nevertheless, many insurers and state Medicaid programs, two groups that typically look more skeptically at services that can drive up costs, are backing telehealth expansion.
And despite initial fraud concerns, nearly a dozen Medicaid and insurance industry officials interviewed for this article noted that thus far they've seen little evidence of widespread misuse.
“There is fraud in traditional medical care, too," said Dr. Donna O'Shea, a senior executive at UnitedHealth Group.
Several insurance officials said telehealth could ultimately save money by routing some medical care from high-cost doctors' offices and hospitals to lower-priced virtual visits, particularly for urgent care.
And some insurance companies — including Harvard Pilgrim Health Care in New England and Priority Health in Michigan — are marketing health plans with lower premiums that steer patients to virtual care.
“We see this being a long-term change," said Dr. Michael Sherman, Harvard Pilgrim's chief medical officer.
Sherman said the health plan is even exploring whether to help low-income patients get internet access to expand telehealth further. “We have proven to ourselves that this works," he said.
KHN correspondent Rachana Pradhan and digital producer Hannah Norman contributed to this report.
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KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.