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Telehealth and the COVID-19 Public Health Emergency

Anna Maria Lopez, Sidney Kimmel Cancer Center and Thomas Jefferson University, moderated the second session, which focused on trends and challenges in telehealth adoption in the context of the COVID-19 public health emergency. The speakers were Celeste Campos-Castillo, University of Wisconsin–Milwaukee; Lok Wong Samson, U.S. Department Health and Human Services (HHS); and Carmel Shachar, Harvard University.

THE IMPACT OF RACE, ETHNICITY, AND LANGUAGE BARRIERS ON TELEHEALTH ACCESS

Celeste Campos-Castillo, University of Wisconsin–Milwaukee

Celeste Campos-Castillo, professor of sociology at the University of Wisconsin–Milwaukee, discussed how telehealth adoption during the COVID-19 pandemic has affected health care inequities.

Campos-Castillo said that the significant expansion of telehealth during the COVID-19 pandemic has brought many benefits. Policies to facilitate telehealth use and reimbursement brought greater flexibility and allowed synchronous and asynchronous interactions between patients and clinicians to meet a variety of health needs, from triaging acute injuries to managing at-home care of chronic conditions. She explained that in many cases, telehealth has been shown capable of reducing health care costs and time burdens. As an example, telehealth has allowed patients to attend appointments without needing to take time off work or make child care or transportation arrangements. Campos-Castillo said policies allowing the use of popular services that were not previously considered Health Insurance Portability and Accountability Act (HIPAA) compliant—such as FaceTime, Zoom, and Facebook Messenger, as well as other technologies that do not require high-speed Internet, English proficiency, or specialized equipment—enhanced health care access and convenience for many patients.

Campos-Castillo explained that despite its advantages, telehealth does not address the racial and structural inequities that have profound effects on health and health care for some communities and were exacerbated during the pandemic. She noted that minoritized communities, which are more likely to have chronic conditions requiring continuous care, were also more likely to be composed of essential workers, which elevated their risk of contracting COVID-19, increasing the potential for stress and economic hardship. The pandemic also led to a decrease in fee-for-service visits and thus clinician revenue. She explained that loss in revenue had an especially negative effect on community health centers, which provide the full spectrum of health care for minority communities and rely on reimbursements.

Campos-Castillo said that research provides intriguing insights into the particular benefits and drawbacks of telehealth for particular communities and suggests that telehealth closes some gaps while exacerbating others. She described a study that included a survey of approximately 10,000 American Internet users conducted in March 2020. Survey respondents who primarily spoke Spanish and did not identify as White reported using expanded telehealth services at higher rates than respondents that primarily spoke English and identified as White because of pandemic-related concerns (Campos-Castillo and Anthony,

2021). She noted that another study found that respondents who spoke primarily Spanish adopted telehealth at higher rates, and she theorized this was in part because some online platforms can be used to facilitate language translation or access to interpreters.

Campos-Castillo described another study focused on mental health care for teens that found this group had a strong interest in protecting privacy and identified different preferences in terms of the mode of communication with health care providers (e.g., telephone, video, text, or in-person visits) among different racial and ethnic groups. Teens’ dramatically increased screen time during the pandemic created conflicts with caregivers, whom they rely on for Internet and device access. Her research showed that a key factor in whether or not teens were able to access telehealth was having a close and trusting relationship with an adult. She explained that while increased screen time has drawbacks, it is important that teens have time, privacy, and any needed training to access telehealth.

Campos-Castillo said that overall, home Internet access is a key factor in determining whether telehealth expands or limits access to care, underscoring the critical role of broadband infrastructure in addressing health inequities. She said that moving forward, policies should support HIPAA-compliant, text-based communication to facilitate asynchronous telehealth and ensure clinician reimbursement for a wide range of telehealth platforms.

TELEHEALTH USE DURING THE COVID-19 PANDEMIC: MEDICARE BENEFICIARIES’ USE OF TELEHEALTH

Lok Wong Samson, U.S. Department of Health and Human Services

Lok Wong Samson, a social scientist in the Office of Health Policy in the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE), discussed trends in telehealth before and during the pandemic and shared data from a recent study on telehealth and Medicare fee-for-service visits (Samson et al., 2021).

Samson explained that before the pandemic, Medicare policies restricted telehealth services to patients living in rural areas, covered a limited set of health care services, and required patients to attend virtual visits from a health care facility using interactive audiovisual technologies. During the pandemic, many of those restrictions were relaxed. Geographic limitations were eliminated and many more services provided via telehealth were included as eligible for reimbursement. Patients were allowed to connect from home, employ audio-only interactions for some services, and use a wider range of teleconferencing platforms.

Samson noted that overall, these changes led to a 63-fold increase in Medicare telehealth visits from 2019 to 2020, with a vast majority (92 percent) of patients receiving telehealth from home. However, this dramatic increase in telehealth use only partially offset the significant reduction in in-person visits during the same period. She noted there was an 11 percent overall reduction in total visits between 2019 and 2020.

Samson said disparities in telehealth reflect the country’s digital divide. Certain populations, including adults with low incomes and those who are age 65 or older, are less likely to have access to the Internet and Internet-enabled devices required for telehealth participation (HHS, 2021). ASPE research found lower telehealth use overall among people who are uninsured and young adults, as well as lower use of video-based telehealth among older adults, people with lower education attainment, and racial or ethnic minorities, all of which are correlated with income (Karimi et al., 2022). Samson said that nevertheless, the expansion of telehealth that came with loosening Medicare policies in 2020—particularly the ability to access telehealth from home—likely contributed to maintaining care access for groups that historically have been made vulnerable. While the increase in telehealth use was not enough to offset the overall decrease in health care visits with the emergence of the COVID-19 pandemic, telehealth did seem to play an important role in maintaining care access. Samson noted particularly marked telehealth adoption among people who were dually enrolled in both Medicare and Medicaid, people who were disabled, people living in urban areas, and those receiving behavioral health care.

Samson hypothesized that because Medicare policies apply equally across the United States, geographic variation in telehealth use and differences in urban versus rural areas may reflect underlying barriers in Internet infrastructure and access, device ownership, and technology comfort and literacy, among other factors. Samson said more investments in these areas are needed to overcome telehealth disparities.

THE EVOLUTION OF EMERGENCY REGULATORY CHANGES FOR TELEHEALTH ACCESS DURING THE PUBLIC HEALTH EMERGENCY

Carmel Shachar, Harvard University

Carmel Shachar is executive director of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School. She reviewed emergency changes to telehealth regulations during the COVID-19 pandemic and discussed the role of clinicians in advocating for a thoughtful transition in

policy after the public health emergency to ensure that telehealth gains made during the pandemic continue into the future.

Shachar explained that changes related to telehealth policies and coverage were authorized under the framework of the federal Public Health Service Act, which enabled the government to declare COVID-19 a public health emergency (PHE) and take needed actions in response to that emergency. The PHE declaration loosens federal and state regulatory requirements, enabling entities to act quickly and responsively to public health needs. She noted that in addition to broadening telehealth use, PHE emergency use authorizations sped the development and implementation of novel COVID-19 treatments and vaccines.

Shachar said that unless those regulatory relaxations are explicitly kept, they will be lost at the federal, state, and private payer level when the federal PHE is lifted. She described how three main regulatory changes that are closely related to telehealth—HIPAA flexibility, Medicare and Medicaid payment, and state licensing requirements—could create significant challenges if they are reversed.

Shachar echoed other speakers, noting that new flexibilities in HIPAA requirements improved care access by enabling the use of an expanded array of telehealth modalities, including popular platforms like Zoom and FaceTime. This change eliminated physicians’ concerns about committing HIPAA violations by using nonapproved platforms. She noted that the American Medical Association recognized the importance of this flexibility and has requested a year-long transitional period before reverting to previous platforms. She also emphasized that if the PHE is lifted, this flexibility in HIPAA-compatible platforms could be removed immediately.

Shachar explained that changes to Medicare and Medicaid also encouraged telehealth use by relaxing restrictions on patient and clinician location, modality, type of service, and reimbursement codes. She said that lawmakers may be concerned that maintaining these changes is too expensive or that they are susceptible to abuse; however, the popularity of these changes may convince Congress to adopt them permanently.

Shachar noted that a final major barrier to improved telehealth is inconsistency in state licensing requirements. This variability creates a patchwork of regulations that makes it virtually impossible to create a national telehealth practice. She explained that most states modified their licensing requirements during the PHE, but if prepandemic rules are reinstated, this problem is likely to return because federal, state, and private payers approach regulation differently.

DISCUSSION

Participants discussed future telehealth practices, policies, and advocacy along with issues around payment parity.

Future Telehealth Practices, Policies, and Advocacy

Lopez asked speakers to comment on how telehealth can best benefit patients going forward. Campos-Castillo replied that it is important to ensure that both video and audio telehealth modalities for people from all age groups, ethnic or racial groups, and locations remain covered. She said that audio-only modalities are especially important because while synchronous video platforms are popular with some groups, they can exacerbate inequities by favoring patients who speak English, are familiar with the required devices, and have reliable high-speed Internet.

Shachar suggested that the perception of telehealth as a mirror of in-person consultations may be oversimplified and too limiting. She said that telehealth presents new opportunities, such as smart home devices for remote patient monitoring that can help to build a stronger, more creative medical system. In addition, she said the current expectation that patients can self-finance devices, Internet access, and health insurance deepens existing disparities.

Georgia Malandraki, Purdue University, and Alan Lee, Mount Saint Mary’s University and Scripps Mercy Hospital, asked about informing and advocating for telehealth policies in the postpandemic period. Shachar suggested that clinicians can play a key role in bringing visibility to the issue: “I would encourage providers to use their voice to call or to email [their representatives] and say, ‘What are you going to do about this telehealth cliff?’” She suggested that regulatory agencies should be given the power to evaluate and retain the changes implemented under the PHE that have been most efficient and most effective. Shachar said that in addition to reaching out to elected officials to advocate for such policies directly, providers should bring the issue to the attention of reporters to amplify the message that removing the PHE declaration could hurt patients and encourage the public to take action.

Campos-Castillo added that community organizations can be important advocacy and organizing partners. In response to a question from Carless Grays, from the Social Security Administration (SSA), she noted that telehealth disparities can be mitigated through a mix of targeted community-based advocacy and nationwide structural changes to policies and technology access to deliver health care across a wide range of modalities and entities.

Payment Parity

Shachar explained that payment parity for telehealth is a complex issue. Telehealth was reimbursed at a discounted rate in many cases before the pandemic. She said if telehealth is less expensive to offer, there should be some savings while also considering office expenses. She also noted that the current policy of payment parity does not reflect the potential economies of scale telehealth offers. Mei Kwong, Center for Connected Health Policy, commented that prior to the pandemic, Medicare and Medicaid reimbursed telehealth and in-person services at the same rate, although it depended on which services were used and in what state. She said that since the pandemic, more state laws are requiring payment parity for video visits, but audio-only payment parity remains unresolved.

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