Telehealth in the COVID-19 Spotlight

By David Gray, Senior Manager, Government Relations & Connected Health Policy, HIMSS

Since the beginning of the novel coronavirus disease (COVID-19) outbreak, telehealth and other connected health technologies have been in the spotlight as a critical tool in healthcare’s arsenal to help reduce the risk of transmission and provide safe, reliable access to care. As confirmed cases of COVID-19 continue to grow at an alarming rate, we are seeing an almost unprecedented embrace of telehealth by the federal government to help connect patients and providers in an attempt to limit the spread of the disease.

While it isn’t possible to diagnose coronavirus through telehealth, it can play a critical role by offering a safe and cost-effective means of identifying and responding to health needs in a public health emergency. Telehealth is a valuable tool for providers to screen patients, answer questions and make recommendations, and ease the burden on day-to-day care delivery so that physicians and hospitals can focus on critical, high-risk patients, while also limiting the risk of exposing others to the virus. Providers can also leverage telehealth to treat patients regardless of geographic location, helping both rural and urban patients equally.

How We Got Here—Congressional and Agency Action to Enable Greater Telehealth Utilization

With the Centers for Disease Control and Prevention (CDC) acknowledging that older populations and those suffering from severe chronic medical conditions, like heart, lung, or kidney disease, are at higher risk of developing more serious COVID-19 illness, it was critical for Congress and the Centers for Medicare and Medicaid Services (CMS) to take action to equip providers and Medicare beneficiaries with a broader range of tools. HIMSS and PCHAlliance joined other key stakeholders in calling for Congress to pass Section 9 of the CONNECT for Health Act of 2019 (S. 2741/H.R. 4932), which would empower the Secretary of Health and Human Services to waive telehealth restrictions for Medicare beneficiaries during national and public health emergencies. This provision, which was originally proposed in a joint HIMSS-PCHAlliance letter in April 2019, was based on a PCHAlliance-developed case study on remote patient monitoring deployed in Japan after the Tsunami in 2011 to maintain and continue treatment for those with high blood pressure who were displaced.

In March 2020, as part of a response to the outpouring of pressure from stakeholders and our congressional telehealth champions on Capitol Hill, Congress passed, and the President signed into law, H.R. 6074, the Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020. The bill contained a provision giving the HHS Secretary the authority to waive certain restrictions on the use of telehealth in Medicare to treat patients during the COVID-19 outbreak. While the section was narrower in scope than Section 9 of the CONNECT for Health Act, and was limited to just the duration of the COVID-19 Public Health Emergency declared by HHS Secretary Azar, it took important first steps in loosening some of the arduous and outdated Medicare telehealth restrictions.

Specifically, this section gave the Secretary the authority to waive applicable originating site and geographic restrictions, including allowing the patient to be at home, for eligible telehealth services. Urban and rural restrictions no longer applied to qualifying originating sites, and it clarified that a smart phone with audio and visual capabilities can be used to have the telehealth visit.

While this was a huge step forward, it came with an expensive Congressional Budget Office (CBO) score of $490 million, and came with additional limitations and layers applied to the waiver. Most importantly, it required that a Medicare beneficiary must have had a Medicare-billed service or visit with their provider (or someone in the same practice as determined by the Tax ID Number) in the last 3 years. A previous relationship from any other payer wouldn’t count. This ran the risk of creating a whole new level of administrative burden to determine the patients eligibility, and would have prevented newly enrolled Medicare beneficiaries who hadn’t seen a provider from using this benefit unless they were in an already-eligible geographic region.

In response to this new authority granted to the HHS Secretary and in light of the potential problems with the language, HIMSS and PCHAlliance circulated a follow-up letter asking for changes to the pre-existing relationship requirements. Additionally, the letter called for Congress to enable providers to utilize home-based remote patient monitoring for symptom escalation to help reduce the risk of transmission and target the provision of hospital-based care on a timely basis should the need arise. To address these concerns, the House of Representatives-passed Families First Coronavirus Response Act (H.R. 6201), the second COVID-19 response bill, included clarifying language that would amend the patient-provider preexisting relationship limitation to instead require any relationship in the last 3 years, broadening it from the previous Medicare-established relationship requirement.

However, before the Senate took up that bill (they are still currently debating it and negotiating changes), CMS has released their much-anticipated guidance clarifying when, where, and how telehealth could be used by Medicare beneficiaries under these new waivers. CMS issued a fact sheet and a list of frequently asked questions to address any confusion on what is and isn’t allowable under these new rules.

Here are some of the biggest takeaways from the new changes to Medicare telehealth efforts to combat the spread of COVID-19:

• Geographic restrictions are waived for all urban and rural areas and the patients home was included as an eligible originating site
• CMS will not enforce any requirement for an established relationship, which is critically important, despite the statutory requirement that a patient must have a relationship with their provider within the last three years
• These new waivers on telehealth services will not be limited to patients with COVID-19, and instead will broaden this flexibility without regard to the diagnosis of the Medicare beneficiary

Further, HHS’s Office for Civil Rights (OCR), which enforces HIPAA privacy and security regulations, issued a Notification of Enforcement Discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. For the duration of the COVID-19 national emergency, OCR will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered healthcare providers in connection with the good faith provision of telehealth.

More Work Still Ahead

HIMSS and PCHAlliance are thrilled to see these far-reaching changes to how Medicare will utilize telehealth to combat the spread of the COVID-19 pandemic. However more must be done to ensure our healthcare system is best equipped to handle the unique challenges we will continue to face as COVID-19 continues to spread across the country. First, Medicare must ensure that providers are able to utilize remote physiological monitoring to treat patients and free up valuable resources for hospitals to treat the most at-risk patients. Second, while the changes to Medicare telehealth are important, they could go further. For example, healthcare providers working in FQHCs and RHCs still aren’t eligible to provide telehealth services. Under statute, those facilities cannot serve as distant sites, only originating sites.

Many healthcare providers, including telehealth providers, are already playing a key role in combating this public health emergency, enabling the timely and effective treatment of patients with telehealth and other connected care technologies. As the crisis continues, it will be imperative that Congress and the Administration provide our healthcare system with as many tools as possible to effectively meet the urgent health needs of our communities.