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Telehealth Study Rates All 50 States On Patient Access To Virtual Care

Many telehealth restrictions lifted during the pandemic have been reinstated

Executive Summary

Several US states hit hardest by COVID-19 have the most restrictive telehealth laws, according to a report from the Reason Foundation, Cicero Institute and Pioneer Institute. As telehealth becomes more integrated into the country’s health care system, states should adopt more reforms so residents can benefit from the advancing technology, the report urges. 

Millions of Americans had a virtual doctor visit for the first time during the COVID-19 pandemic. And though telehealth was growing in popularity before the coronavirus arrived on the scene, the number of virtual visits skyrocketed as lockdowns and social-distancing requirements made them safer and more practical than traditional visits.

In response, federal and state officials made it easier to access telehealth, such as through changes to Medicare policies on telehealth reimbursements, and by executive orders at the state level removing barriers for providers to offer telehealth services. 

Illustrating how prominent telehealth has become since the pandemic, US lawmakers in September issued a bipartisan resolution in recognition of the first Telehealth Awareness Week. (Also see "Congress Marks First Telehealth Awareness Week" - Medtech Insight, 24 Sep, 2021.)

However, while many of these measures increased access to care that otherwise would not have been possible, many of these policies and executive orders were withdrawn as pandemic restrictions were lifted, according to a new report from the Reason Foundation, Cicero Institute and Pioneer Institute, “Rating the States on Telehealth Best Practices: A Toolkit For A Pro-Patient And Provider Landscape.”

Further, many of these changes on the state level were incremental, according to the report, because policymakers lacked a best-practices roadmap on how to implement them.

The report’s authors, Vittorio Nastasi, policy analyst at the Reason Foundation, and Josh Archambault, senior fellow at the Cicero Institute and the Pioneer Institute, say that while telehealth visits “cannot and should not” replace all traditional visits, they can, however, save time and resources while keeping patients safe by allowing them to avoid waiting rooms, which are potential hotspots for infection.

“Telehealth could have the greatest impact on communities that have been underserved, especially rural and lower-income communities and the elderly.” – Vittorio Nastasi

Telehealth can also benefit providers, the authors say, by reducing their risk for exposure as well and lessening the pressure on already overtaxed hospitals.

Notably, the report finds many states hit hardest by the pandemic, such as New York, California and Connecticut, have some of the most restrictive telehealth laws. These states, for instance, have not signed up for interstate licensing compacts and have coverage parity mandates that offer no flexibility between the insurer and provider.

Only three states, according to the report – Arizona, Florida and Indiana – allow all providers to easily practice telehealth across state lines, while the other 47 have arbitrary barriers in place that limit a patient’s access to a specialist and available appointments based purely on residency.

The authors do note, however, that almost all states – except Tennessee – have removed the pre-pandemic requirement that a patient must see a provider in-person before using the telehealth option, while Alaska and West Virginia still require a traditional visit for some telehealth services. Another 20 states, the report finds, allow full independent telehealth practice for nurse practitioners without the supervision of a physician.

Reforms Needed

With many of the lifted and eased restrictions to telehealth accessibility coming back in place, Nastasi told Medtech Insight reforms are necessary to unlock telehealth’s full potential, and that the aim of the report was to establish a set of telehealth best practices and identify areas for improvement in each state.

“The best practices we identify are intended to maximize choice and flexibility for patients and providers,” says Nastasi, pointing to the rise in telehealth since the start of the pandemic, which despite having fallen since its peak remains well above pre-pandemic levels. “All of this means that millions of Americans tried telehealth for the first time during the past two years. And polling consistently shows that patients are likely to continue using telehealth after the pandemic ends. States must act to update their laws for their patients.”

Maintaining the “no in-person” requirement for telehealth authorization is an essential component to these best practices, the authors argue, even without the obvious benefit to reducing infections during a pandemic. Telehealth options, the authors say, offer care to those in areas where providers are in short supply and people with transportation challenges.

“Telehealth could have the greatest impact on communities that have been underserved, especially rural and lower-income communities and the elderly,” Nastasi says. “Ideally, telehealth would eliminate geographic barriers to access, allowing anyone to access care regardless of their physical location. This is particularly important in the case of specialty services that might not otherwise be available in a patient’s area.”

As Nastasi points out, telehealth allows rural hospitals to offer more services and provides innovation, such as team-based care for patients dealing with diseases like diabetes.

Another best practice the authors favor is the adoption of a “modality-neutral” definition for telehealth delivery, which means allowing for many kinds of telehealth, not just live video. Modality-neutral, according to the report, was defined by the American Telemedicine Association (ATA) and includes various methods for providing virtual care. 

Removing Barriers

Barriers to accessing telehealth across state lines is another best practice outlined in the report. Allowing patients to access providers outside their community is imperative as most cities and towns simply lack certain kinds of providers. As the authors point out, telehealth, in some cases, may be a patient’s only option to see a specialist, to get a second opinion, or access team-based care. 

“The beauty of telehealth is that it can be accessed from a smartphone using mobile data as long as state law does not erect barriers to such access.” – Vittorio Nastasi

States should also remove coverage mandates, the authors say, because not all telehealth is created equally. For instance, the report cites a comprehensive research review in 2018 by the Medicare Payment Advisory Commission (MedPAC), an independent agency that advises Congress on Medicare practices, that found telehealth could be a “game changer” for post-stroke care, and for treatments for physically disabling and treatment-intensive conditions. Yet for other services, the evidence of better outcomes is far less certain.

Most state laws need to protect flexibility, the authors argue, so new innovative models can emerge, and best practices for telehealth can be data-driven.

The authors are also against “payment parity,” which essentially means that telehealth services are required to be reimbursed at the same rates as in-person office visits.

“These mandates are intended to promote the use of telehealth but have unintended consequences,” says Nastasi, noting that one of the many advantages of telehealth is that services can be rendered from any setting, both for the patient and provider. “So, it makes little sense that policy should mandate the same payment rate, including in many cases a facility fee, even if the service is delivered from a home office. For patients this matters as mandates inflate prices, and since many patients have a deductible with their insurance, they are paying the full cost of any telehealth visit.”

Studying telehealth across the entire country, Nastasi says Florida and Arizona perform best according to the report’s ratings, both having created telehealth registration processes that allow out-of-state providers to practice telehealth without obtaining an additional license.

“In practice this means that sick patients don’t have to travel to be in touch with great providers, and that someone’s geography doesn’t have to determine their access to care,” he says, adding that Florida takes a slight edge over Arizona because Florida does not have coverage or payment parity. But conversely, Vermont, Iowa, Wisconsin and Wyoming fall short on the metrics in which all other states score well.

Regardless of what happens in Washington, DC, and in state legislatures across the country, telehealth – at least the demand for it, and its ability to augment health care for millions of Americans – is here to stay.

“The beauty of telehealth is that it can be accessed from a smartphone using mobile data as long as state law does not erect barriers to such access,” Nastasi says. “Telehealth also can help delivery 24/7 on-demand care for those wanting to kick an opioid addiction or dealing with a mental health crisis, instead of only being able to go to the emergency room in the middle of the night. That is why getting telehealth policies right is so important.”



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