Healthcare providers and telehealth vendors could be forgiven for raising their collective hopes of a clear path forward as the US COVID Public Health Emergency (PHE) formally ended on 11 May.
But any notion that the less restrictive measures that really launched telehealth in 2020 and 2021 would become permanent in law were dashed last month as another temporary set of extensions were approved.
While any extension is better than none, they are no real cause for celebration. For a healthcare industry crying out for long-term legal and regulatory certainty around telehealth, virtual care and remote patient monitoring (RPM), the latest temporary extensions until this November (for drug prescriptions) and December 2024 (for a raft of other measures) smack of the US health authorities kicking the can down the road once again.
The Signify View
As the curtain finally came down on the PHE on 11 May, the US Drug Enforcement Administration (DEA) and Substance Abuse and Mental Health Services Administration (SAMHSA) were extending temporary legislation granting physicians powers to prescribe controlled medicines to patients virtually for another six months until 11 November.
The move is one of several temporary extensions confirmed last month. Until December 2024 Medicare patients will still be allowed virtual consultations with physicians from anywhere (before the pandemic a patient had to sign in for a virtual consultation from a designated, CMS-authorised location, and this was almost exclusively in rural areas). Physicians, meanwhile, will still be able to provide a virtual consultation without first meeting the patient face-to-face. And audio-only communications for non-behavioural health consultations will also be permitted until the end of next year.
These emergency measures, along with the CMS relaxing compliance standards on IT used in virtual care platforms, the allocation of specific CPT and HCPCS reimbursement codes for virtual consultations and RPM, and the introduction of ‘payer parity’ (giving equal reimbursements for in-house or virtual ‘visits’) really launched telehealth.
Yet almost three-and-a-half years on, the continued reluctance (or inability) of US lawmakers to pass legislation making emergency measures permanent is now keeping providers and telehealth vendors in limbo.
But why the reluctance?
Cost is one factor. Although in theory telehealth helps prevent adverse or acute events, virtual care also lowers barriers to accessing healthcare. As such it can, ironically, have the opposite effect of increasing overall healthcare costs.
Any increase in the number of consultations (virtual or in-person) in a fee-for-service environment means greater amounts of reimbursement must be paid out. This money ultimately comes from the Medicare Trust Fund, and there are questions about the Fund’s solvency.
It is therefore understandable why the CMS might have cost concerns.
However, if cost containment is the CMS’s main motivation for extending the temporary measures by another 18 months in many cases, it is a short-sighted approach with potentially damaging consequences. Lacking visibility beyond December 2024, some providers will simply delay the implementation of new workflows and some vendors will defer investments in new platform innovations. The Acute Hospital Care at Home (AHCaH) initiative is a prime example of where uncertainty in relation to long-term reimbursement structures is hurting the industry.
This at a time when the US healthcare industry, faced with rapidly escalating costs, a staffing crisis and myriad other challenges, needs better workflows, new investment and innovations more than ever.
No Going Back
Healthcare stakeholders are, however, starting to take matters into their own hands. For many ‘bricks and mortar’ providers, virtual care is already an integral part of the business model. Meanwhile, large organisations like retail pharmacies CVS and Walgreens are now making substantial plays in virtual care.
There is a sense that providers and vendors have come too far down the track to turn back after December 2024.
The mood music in Washington strikes a similar note. In the wake of its six-month extension to the medicine prescription rules last month, DEA Administrator Anne Milgram acknowledged that the agency was reviewing comments from the public and other stakeholders ‘in order to develop a permanent rule’. She added that the additional six months would enable the DEA to ‘find a way forward to give Americans that access (to telemedicine) with appropriate safeguards’.
And the journey towards permanent legislation has, in fact, started. Reimbursements for virtual consultations in the fast-growing behavioural and mental health space in the US are now enshrined in law. As a result, behavioural and mental health patients will never again need to attend a CMS-designated ‘originating site’ to get a prescription.
Lawmakers will be watching closely at how this development pans out as they debate the four bills (Connect the Health Act, Telehealth Modernization Act, Protecting Access to COVID-19 Telehealth Act and the Telehealth Extension Act) currently doing the rounds in Congress.
Concerns around the lack of visibility beyond 2024 extend beyond virtual consultations.
The PHE was a driving force behind the so-called ‘hospital-at-home’ market. Here, the AHCaH initiative is still a temporary measure, and this is having a negative impact on the hospital-at-home RPM use case.
Separately, for the second main pillar of RPM (chronic condition management), the reimbursement codes are already permanent. But the stipulation that RPM devices could only be prescribed for chronic conditions if the patient had already had in-person consultations with the provider was tied to the PHE, and was relaxed during the emergency. These more relaxed rules have again been extended on a temporary basis, but what happens after that is cause for concern.
That said, in the ‘worst case scenario’ that the measures are rolled back and we effectively regress to pre-COVID days, the impact will be limited. Most patients with a chronic condition that needs to be monitored remotely maintain face-to-face relationships with their provider over time anyway.
While the latest extensions to temporary COVID-era measures are far from a disaster, they are not particularly helpful for a telehealth market looking to kick on having plateaued since 2022.
The US healthcare industry also needs that clarity of vision so it can address the big challenges of the day: the staffing crisis, making care more accessible to more of the country’s population, and driving the rollout of value-based care.
The smart money, of course, is on the temporary measures finally becoming permanent when the latest extensions expire.
In the meantime, the CMS would do well to look at how telehealth vendors and healthcare providers engage with commercial payers, where there is greater clarity in the longer-term structures of commercial relationships. Could government payers learn from this?
The end of the PHE at least focuses minds and forces Congress to act. Come December 2024, providers, telehealth vendors and the American public will no longer tolerate any more uncertainty over the future direction of telehealth.
In many respects, however, the point of no return has already been reached.