Infectious Disease

Telehealth’s future uncertain as restrictions tighten

March 03, 2023

7 min read

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Disclosures:
Downey reports no relevant financial disclosures. Nowell reports institutional research support from AbbVie, Eli Lilly & Co., Janssen and Scipher Medicine. Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs Inc., Adept Field Solutions, Clinical Care Options, Clearview Healthcare Aartners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM LLC, Trio Health, Medscape, WebMD, Practice Point Communications, the NIH and the American College of Rheumatology; institutional research support from Zimmer Biomet Holdings; food and beverage payments from Intuitive Surgical Inc./Philips Electronics North America; stock options in TPT Global Tech, Vaxart Pharmaceuticals, Atyu Biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics Inc., Seres Therapeutics, Tonix Pharmaceuticals Holding Corp. and Charlotte’s Web Holdings, Inc.; speaking fees from Simply Speaking; and executive membership with Outcomes Measures in Rheumatology (OMERACT).

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The regulations and reimbursement structures surrounding telehealth that were loosened during the height of the COVID-19 pandemic have begun to tighten again, and could have significant implications in rheumatology.

“A silver lining of the COVID-19 pandemic was the increased availability of telemedicine, particularly for people living with chronic, rheumatic diseases who needed ongoing care, but also benefitted from remote care given their heightened risk for infection and associated complications,” W. Benjamin Nowell, PhD, director of patient-centered research at the Global Healthy Living Foundation and CreakyJoints, told Healio in an interview.

Quote from Downey

The regulations and reimbursement structures surrounding telehealth that were loosened during the height of the pandemic have begun to tighten again.

As the fear and stress of the pandemic have eased, patients have fallen into two groups regarding telehealth preferences, according to Jasvinder Singh, MD, MPH, professor of medicine and epidemiology at the University of Alabama at Birmingham, director of the Gout Clinic at the University of Alabama Health Sciences Foundation, and a staff rheumatologist at the Birmingham Veterans Affairs Medical Center.

W. Benjamin Nowell

Jasvinder Singh

“For one group of patients, the relaxed restrictions on telehealth were a real blessing,” he said.

This group included many patients in rural areas for whom significant time and costs — either in travel, lost work or both — were required to see their doctor.

“Those patients are demanding that we continue to do telehealth visits,” Singh said.

However, there is another group of patients who were essentially “forced” to use telehealth during COVID-19, and would much rather return to in-person visits as the norm, according to Singh.

“They felt the quality of the visit was not as good, and will avoid telemedicine moving forward,” he said. “Many of them are older patients, or those who are uncomfortable with technology.”

This duality in patient preferences runs parallel to the shifting, sometimes ambiguous legal landscape — not to mention insurance reimbursement structures — surrounding telehealth around the country. States like Alabama have moved to tighten restrictions again and return patients to the clinic, while others, like Illinois, have ensured that certain groups of patients can continue using telehealth for the foreseeable future.

Either way, the rheumatology community is paying attention.

“We continue to monitor state telehealth legislation and are working to ensure that patients and providers have the necessary flexibilities so that patients have timely access to care,” Christina Downey, MD, of Loma Linda University Health in California, and chair of the American College of Rheumatology’s Government Affairs Committee, told Healio.

The current moment is an inflection point. Telehealth uptake, regulation, administration and reimbursement all hang in the balance, and the way the dust settles in the next few months could determine how rheumatologists implement the technology in daily practice for years to come.

Shifting legal landscape

In Alabama, Senate Bill 272 and House Bill 423 both aim to mandate in-person visits for certain services. Supporters of the bill argue that in-person visits are critical to maintaining the doctor-patient relationship.

Proponents also have argued that doctor visits using a telephone or smartphone only are insufficient to conduct adequate health assessments and care.

“Video telemedicine is still being compensated by a significant proportion, but telehealth using just audio or telephone is not as much,” said Singh, who practices in Alabama. “That is a big change in our view.”

A proposed bill in Alaska, meanwhile, aimed to mandate an in-person visit before telehealth services can be initiated. However, this bill was voted down in committee.

Conversely, in Illinois, Gov. J.B. Pritzker extended an executive order protecting telehealth for mental health care and patients with developmental disabilities through Jan. 6, 2023, and then again through Feb. 4, and then yet again through March 4.

In Ohio, H.B. 509 was recently passed, which will allow for independent school psychologists and optometrists to practice telehealth. This legislation may indicate that Ohio could be open to continuing telehealth use in other fields, including rheumatology, even as other pandemic protocols subside.

“We appreciate that policymakers are expanding regulations to allow telehealth to be a supplemental part of health care delivery,” Downey said. “We look forward to working with regulators to provide a framework that will allow telehealth to be a valuable and complimentary form of care delivery without sacrificing and replacing in-person encounters.”

For Downey, it is critical for patients to continue to have the flexibility to see providers either virtually or in-person. She added that “audio-only” visits should also be available for patients who would prefer them.

“With the inevitability of the public health emergency expiration in 2023, we welcome the inclusion of telehealth as a tool for delivering care,” Downey said. “However, we firmly believe telehealth should be considered supplemental to in-person care.”

Nowell agreed, stating that although in-person visits will remain key for physical assessments and maintaining personal relationships between patient and provider, the continued use of telehealth can, and should, expand.

“At CreakyJoints, we would like to see more rheumatologists offer telehealth options, particularly if follow-up appointments are intended for simple delivery of lab results or discussion of treatment options,” he said. “Of course, in person visits remain important to build the provider and patient relationship and to collect physical data, but given that patients prefer to have telehealth options, we’d like to see that option become more standard.”

President Joe Biden recently announced the COVID-19 public health emergency will end May 11. Whether telehealth will be available to all, supplemental in certain scenarios or eliminated altogether remains to be seen. What is certain is that more data on telehealth and its impacts would shed some additional light on the role tele-rheumatology could play in patient care moving forward.

‘Struggling’ to stay connected

On Nov. 7, 2022, the Center for Medicare and Medicaid Innovation (CMMI) at CMS released a report containing updated strategies for quality, patient-centered care at an affordable cost. Tools such as e-consults were considered in the report, highlighting the idea that if telehealth is to be standardized across the country, several technological challenges must be resolved.

“As telehealth became the primary point of care during the public health emergency, we quickly experienced challenges and lessons related to telehealth, including poor internet access, patients unfamiliar with audio-visual technology, and privacy fears related to showing a provider their surroundings,” Downey said.

As these concerns emerged, patients and providers adapted, she added.

“The audio-only component of telehealth allowed providers to see every patient, regardless of these challenges,” Downey said.

According to Nowell, other challenges may be addressed by including clear, accessible instructions and offering multiple language options.

“We would suggest that rheumatologists develop easy-to-understand instructions for how their patients can access telehealth and, ideally, offer those services in multiple languages, depending on their local patient population,” he said.

However, Singh described an important sticking point in the technology that he said must be addressed if telehealth is to become routine.

“The spread and availability of technology in the United States is not uniform,” Singh said.

In fact, despite the loosened restrictions on the use of telehealth during the pandemic, many rheumatologists and their patients “struggled” to stay connected, he added.

“We are now struggling even more because people are moving,” Singh said, noting that as patients change locations or homes, they may have long gaps in communication before setting up internet access.

According to Singh, such a big problem of unequal internet access across the United States requires big solutions.

“Ten years ago, a smartphone and reliable Wi-Fi access was not a necessity in the United States,” he said. “But now, as we move into 2023, this is a basic requirement, and so I think that the opportunity to provide a $50 phone and free Wi-Fi to all Americans who are unable to obtain these services themselves is not too much to ask.

This service could be provided by the federal government or individual states, potentially through Medicare or Medicaid, or private insurance companies, he added. Another option, which may be attractive in states where there is resistance to expanding social programs, would be a system where patients can earn these services, according to Singh.

“However it happens, we really need these tools, not just to connect patients with their health care provider, but also with jobs and communities,” he said.

Technology is not the only hurdle to widespread uptake of tele-rheumatology. Reimbursement for remote visits increasingly has become a struggle as insurance carriers move out of the emergency phase of the pandemic.

‘Critical’ reimbursement

On Nov. 2, 2022, CMS released a final ruling for the Medicare Physician Fee Schedule for calendar year 2023. Changes pertaining to telehealth include adding permanent coverage for prolonged services in some settings as well as for chronic pain therapy and management, and discontinuing coverage for some temporarily covered telehealth services 151 days after the end of the COVID-19 public health emergency.

“Through our work with the Alabama Rheumatology Society, we are making our voices heard with Blue Cross Blue Shield, telling them that this is a real need for our patients,” Singh said. “Telehealth is not going to go away, so we need to figure out some way to keep the option open for our patients. Reimbursement is a critical component of that.”

Other governmental organizations have heard this message. In September, the HHS Health Resources & Services Administration released a draft policy information notice that outlined key criteria for providing telehealth services to patients within the agency’s health center program project. According to the notice, responsibilities for each staff member, as well as billing considerations and compliance with all federal and state regulations, for telehealth services should be clearly delineated. The document also contains stipulations for standardizing the intake process and record-keeping for all patients being treated with telehealth services.

Meanwhile, it may be useful to stress to insurance carriers that more patient access to health care will be beneficial not only to public health, but to their bottom line, according to Singh.

“If we can show that having access to health care through technology can improve patient health, maybe insurance payers can take part of the burden of providing devices for patients,” he said.

Although convincing insurance carriers to widen their coverage structures may be challenging, experts like Nowell believe that the future already is here when it comes to telehealth — whether stakeholders are prepared for it or not.

“Regardless of age, cultural dynamics, or residential location, our society is getting increasingly comfortable with communicating digitally, whether it is a text string with our families, working from home and participating in Zoom calls, or visiting the doctor from our living room,” he said. “Increasing the validated tools that patients can successfully learn to use to share symptom or disease activity data with their doctors, we believe, will increasingly become the norm in medicine. Done well, telehealth can increase access to health care and reduce healthcare disparities.”

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