Clinically Based Policy Decisions: In-Person Requirements for Telehealth Create Unnecessary Barriers

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Medicare's in-person requirement threatens access to quality care.

COMMENTARY

By this time last year, telehealth had become a household word. From March 2020 to June 2020, 30% of all outpatient care was delivered via telehealth, versus 0.8% in 2019.1 Today, telehealth is becoming a standard tool in care delivery as health care clinicians strike an appropriate balance of in-person and virtual care. Moving forward, we expect telehealth to account for 20% to 30% of care delivery.

Fortunately, Congress passed a provision in the Consolidated Appropriations Act in 2020 to increase access to telemental health services by permanently waiving historical Medicare restrictions like the geographic requirement for these services. However, the provision included an unexpected and unnecessary in-person requirement: Physicians must see their patients in-person at least 6 months prior to their telemental visit before Medicare will reimburse for the telehealth visit.

The American Telemedicine Association (ATA) strongly opposes statutory in-person requirements, as they create arbitrary and clinically unsupported barriers to accessing affordable, quality health care.2 Requirements such as these could negatively impact those in underserved communities who may not be able to procure an in-person exam due to provider shortages, work, lack of childcare, and/or other resources.

Clinical Consensus

There is no clinical evidence for an arbitrary in-person requirement before a patient can access telehealth services. In fact, evidence has demonstrated that telemental services like telepsychiatry are just as effective as in-person visits.3 Further, there is clear consensus that a provider can establish a relationship with a patient via a telehealth visit.

The Federation of State Medical Boards, the association of state regulators that oversees standards of medical care, stated that “the relationship is clearly established when the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an encounter in person between the physician (or other appropriately supervised health care practitioner) and patient.”4

A Health System in Crisis

Even before the COVID-19 public health emergency, the health care system in the United States was in crisis, with dramatic provider shortages, an aging population that required more and more health care services, and the explosion of chronic diseases. Although the numbers of aging and chronically ill patients continues to grow, the deficit of health care clinicians is expected to reach a quarter of a million by 2030.5

As demonstrated during the pandemic, telehealth increased the capacity of health care providers across the country by removing geographic and other physical barriers. Telehealth was a lifeline for clinicians and patients during the public health emergency; this could be arbitrarily and instantly severed if the in-person requirement is enacted.

Furthermore, recent data from the Centers for Disease Prevention and Control demonstrated that 23% of American adults do not have an existing relationship with a health care provider, a statistic that is alarmingly high in minority populations.6 In the case of telemental health, explicitly denying a patient’s access to care based on their inability to find a scarce mental health clinician is simply unreasonable.

Supporting a Hybrid Approach to Quality Care Delivery

Simply put, the in-person requirement for telehealth services is at odds with the direction telehealth policy has moved over the past decade. Medicare, historically, has remained deferential to state laws on professional practice requirements and clinical standards of care. Today, no state practice of medicine law in the United States requires a prior in-person visit.

We as a society must support the availability of life-saving care for all Americans, regardless of whether they have an established relationship with a medical provider. The ATA urges Congress to ensure telemental health services continue post-pandemic and defer to states and individual payers to determine telehealth prerequisites. For the Medicare program, Congress should work with the Department of Health and Human Services (HHS) to ensure the HHS Secretary has the authority at the regulatory level to implement any appropriate health care requirements. By explicitly limiting care in statute, legislators will unnecessarily stifle innovation and tie the hands of regulators, providers, and patients.

It is important to note that there will always be an important role for in-person care. Telehealth is simply another tool for clinicians, within the requirements of their license and the appropriate standard of care, to deliver quality care to patients where and when they need it, and it should be regulated accordingly.

Over the past 18 months, it has become clear that there must be a 2-channel system of care delivery, appropriately balancing in-person and virtual care. A hybrid approach to care delivery is the only way our health care system will survive, and the only way all Americans will receive quality, affordable, and convenient care in a post-COVID world.

Dr Kvedar is chair of the board of the American Telemedicine Association, and the editor of njp Digital Medicine. He is also a professor at Harvard Medical School and senior advisor of Virtual Care at Mass General Brigham. Dr Pender is president of the American Psychiatric Association and clinical professor of psychiatry at Weill Cornell Medical College.

References

1. HealthLeaders. ATA-Chair:-Telemedicine-Choices-In-Next-Few-Months-Will-Shape-The-Next-Decade. Accessed September 9, 2021. https://www.healthleadersmedia.com/technology/ata-chair-telemedicine-choices-next-few-months-will-shape-next-decade

2. ATA. ATA-Overview-of-In-Person-Requirements. Accessed September 8, 2021. https://www.americantelemed.org/wp-content/uploads/2021/06/ATA-Overview-of-In-Person-Requirements-1.pdf

3. American Psychological Association. How-well-is-telepsychology-working? Accessed September 9, 2021. https://www.apa.org/monitor/2020/07/cover-telepsychology

4. Federation of State Medical Boards. Model-Policy-for-the-Appropriate-Use-of-Telemedicine-Technologies-in-the-Practice-of-Medicine. Accessed September 9, 2021. https://www.fsmb.org/siteassets/advocacy/policies/fsmb_telemedicine_policy.pdf

5. Behavior Health + Economic Networks. Addressing-the-Behavioral-Health-Workforce-Shortage. Accessed September 9, 2021. https://www.bhecon.org/wp-content/uploads/2016/09/BHECON-Behavioral-Health-Workforce-Fact-Sheet-2018.pdf

6. Kaiser Family Foundation. Adults-Who-Report-Not-Having-a-Personal-Doctor/-Health-Care-Provider-by-Race/-Ethnicity. Accessed September 9, 2021. https://www.kff.org/other/state-indicator/percent-of-adults-reporting-not-having-a-personal-doctor-by-raceethnicity/?currentTimeframe=0&selectedDistributions=all-adults--white--black--hispanic--asian-native-hawaiian-or-pacific-islander--american-indian-alaska-native--other&sortModel=%7B%22colId%22:%22All%20Adults%22,%22sort%22:%22desc%22%7D

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