Sustaining the telehealth revolution

This article was originally published in the Fall 2024 edition of the IDF ADVOCATE newsletter. You can download or request a free print copy of the ADVOCATE.

Telehealth, also known as telemedicine or remote medicine, allows patients to ‘see’ and interact with their healthcare providers without being in the same, physical location. It can include phone calls, video appointments, remote monitoring of vital signs, and communicating via secure email or chat. By necessity, the pandemic accelerated the adoption of remote technologies in healthcare; but even after four years, telehealth is still not fully integrated into the U.S. healthcare system. 

One of the biggest benefits of telehealth for those with primary immunodeficiency (PI) is the ability to see providers without being in high-risk environments, such as crowded doctor’s offices. In addition, because there are so few clinicians with experience treating PI, telehealth provides more individuals with access to expert providers who may not be located near them. 

Medicare and telehealth

As in many areas, Medicare sets the tone for how other public and private insurers handle telehealth. Prior to the pandemic, Medicare coverage for telehealth services was extremely limited. Many state Medicaid programs followed suit. Private insurers were generally more expansive in their coverage, but it varied widely. 

Medicare’s pre-pandemic limitations included:

• The person receiving telehealth had to live in a Department of Health and Human Services (HHS)-designated rural area. 
• Telehealth services had to be provided to the person in a medical setting, such as a doctor’s office, clinic, or hospital. Beneficiaries could not receive telehealth services at home.
• Services had to be delivered using real-time audio/video communication.
• Providers could not remotely prescribe controlled substances, such as certain medications for behavioral and mental health conditions, unless they had seen the patient in person first.

At the start of the pandemic, HHS quickly realized that allowances needed to be made so that people could receive medical care as safely as possible. Medicare beneficiaries were granted much wider coverage for telehealth, including being able to receive services no matter where they lived and being able to receive services at home. Some of these ‘flexibilities’ were made permanent by legislation passed in recent years. For example, there are no longer geographic limits on receiving behavioral/mental telehealth services and beneficiaries can receive them in a variety of places, including at home—but only if the provider saw the patient in person within the prior six months.

However, some of the most impactful Medicare ‘flexibilities’ are set to expire at the end of 2024. Without action from Congress, Medicare will no longer cover non-behavioral/mental telehealth services unless the beneficiary lives in a rural area and the beneficiary will once again have to receive those services in a medical setting.

The Telehealth Modernization Act (H.R. 7623) would make all of the telehealth flexibilities HHS introduced during the pandemic permanent. Many expect Congress to instead extend the flexibilities again for an additional two years, providing time for advocates to get permanent legislation passed.

Lingering telehealth issues

Even if all pandemic-era Medicare telehealth flexibilities become permanent, there are still barriers that prevent telehealth’s full use.

Except in states that have addressed these issues specifically, private insurers are not required to cover telehealth services. They can also impose different requirements (e.g., prior authorization, out-of-network benefits) and reimbursement rates for comparable telehealth and in-person services. Lower reimbursement rates discourage providers from offering telehealth services in the first place.

Patients face another significant barrier in state-based provider licensing. In most cases, patients can only ‘see’ providers who are licensed in the state the patient is in—literally—at the time of the encounter. For example, if a patient is traveling out of state, their home-state provider cannot provide remote care unless the provider also happens to be licensed in the other state. Most providers are only licensed in the state where their practice is located. 

During the public health emergency (PHE), numerous states loosened regulations to allow out-of-state providers to provide telehealth services to their residents. However, many of those allowances disappeared with the PHE. Some states have entered into compacts or other agreements that ease the burden for providers if they choose to pursue licenses in other states that belong to the compact. However, patients are still far from being able to see an out-of-state provider as a normal part of their care.

Finally, the lack of communications infrastructure, especially broadband internet, prevents use of telehealth in remote and other underserved areas. Without broadband, areas of the country where telehealth could be most beneficial in filling access gaps remain cut off.