What is telehealth?
Telehealth involves using technology to facilitate healthcare interactions but has not been used extensively in Medicare in the past. The use of telehealth may be particularly relevant where there are geographic barriers such as a lack of local providers or a public health emergency such as the coronavirus pandemic. There are a number of uses for telehealth including direct patient care and provider to provider communications. Examples of direct patient care include real-time video visits. Provider-to-provider communications include case reviews or consultations such as a specialist providing information to a family physician. The four modes of telehealth as most commonly categorized are shown in Figure 1.
- real-time care with a provider via video or phone
- asynchronous communication between patients and providers
- electronic communication between providers
- use of medical devices to transmit health information
Figure 1: Modes of Telehealth
How have telehealth services delivered to Medicare beneficiaries changed during the COVID-19 Public Health Emergency?
COVID-19 has changed many things including how we gather with friends and family, shop for essentials, and receive healthcare. Changes are particularly pronounced for Medicare beneficiaries who are at higher risk than the general population. Prior to the pandemic, Medicare only covered telehealth services provided via HIPAA-compliant video technology to patients located in designated rural areas delivered by certain providers. As a result, uptake was low, and less than one percent of all Medicare beneficiary visits involved telehealth prior to the COVID-19 public health emergency (PHE).
As noted in our previous blog posts, there were a number of telehealth-related policy changes due to the COVID-19 PHE. Many of these changes allow Medicare beneficiaries to seek virtual care from the safety of their own homes. Prior telehealth reimbursement was restricted based upon service, rurality of patient, and limited services to select sites. Delivery of telehealth also required the use of technologies that were compliant with HIPAA. This excluded commonly used technologies such as Facebook, Skype, or Microsoft Teams. With the telehealth policy exemptions made by CMS detailed in Figure 2, Medicare fee-for-service (FFS) beneficiaries began to access telehealth services at unprecedented levels. As a result, telehealth visit volume increased. With vaccinations now rolling out across the country, the future of telehealth remains uncertain. What happens to the demand for and availability of telehealth services for Medicare FFS beneficiaries after the COVID PHE ends?
Figure 2: COVID-19 Public Health Emergency (PHE) Telehealth Policy Provisions
How did telehealth use change during the coronavirus pandemic?
Telehealth visits via video and phone quickly became essential to providing healthcare during the PHE. Many health care organizations quickly moved to provide telehealth services in March and April of 2020. Therefore, in the first ten months of the pandemic in the United States, telehealth became the norm. Going back to the pre-pandemic state will be challenging since providers and patients expect to have access to the services. To illustrate this trend, in January of 2020, telehealth comprised less than 1% of all Medicare beneficiary visits, peaking in April 2020 with 40.9% of all visits. Telehealth visits decreased to 19.9% of total visits in the Summer of 2020 as detailed in Figure 3. Similarly, private insurance claims [pdf] in November 2020 followed this same trend when telehealth claims made up 6% of all claims compared to less than 1% in 2019.
Figure 3: Primary Care Visits and Telehealth Adoption by Month 2020
| Note: Primary Care visits for FFS Medicare beneficiaries 2020, Author’s calculations |
What will the future demand for telehealth look like?
We do not expect the demand for telehealth to decline after the coronavirus pandemic. Providers and patients are accustomed to the virtual care environment. We have seen that patients with barriers to accessing care such as transportation appreciate the ability to receive services over the phone or video. This can result in improved maintenance of care.
When asked, 20-24% of Medicare beneficiaries indicated that their primary care provider offered telehealth prior to COVID-19 (as shown in Figure 4). Many will want to keep those services, but we may not return to either the pre-pandemic 1% telehealth usage or the 40% peak usage. Virtual visits have settled around 20% so far. In addition, in-person visits have declined by over 45% since the pandemic. In fact, over 40% of U.S. adults delayed or skipped medical care because of the PHE. This means that there may be some delayed care or missed care. Thus, we may see that delayed needs drive virtual care use back up in the coming months.
Figure 4: Telehealth Services Availability Throughout COVID-19 PHE Across Metro/Non-Metro and Income Level
| Note: Author’s calculations |
What about inequities in access to telehealth?
As the pandemic progressed, the gap between those with access to telehealth services and those without grew. Some of the reasons for the gap include consistent access to the internet and an internet-enabled device. The widest gap exists between beneficiaries in Metro areas making more than $25K per year and those in Non-Metro making less than $25K per year. These vulnerable individuals would potentially seek care and treatment sooner if telehealth were easily accessible. There is even the potential to reduce the presentation of higher acuity patients if telehealth becomes an increasing option for individuals in rural areas and those making less income. Above all, patients would more easily receive services for behavioral health and have earlier access to detection and lifestyle monitoring to reduce future high acuity and specialist services need.
However, these widening inequities in care since the presentation of telehealth must be addressed. There are several telehealth bills before Congress and proposed rules from CMS. There is uncertainty around services that will be covered, who will have access to these services, which providers can see which patients due to licensing, and a patient’s general proclivity for telehealth adoption.
What happens when the COVID-19 PHE ends?
As COVID-19 vaccination distribution continues, there are questions about which PHE telehealth provisions will remain in place when the health crisis ends. In the 2021 Physician Fee Schedule (PFS) Final Rule, CMS addressed an expanded list of Medicare-covered telehealth services and coverage of telephone-only visits. The Final Rule covers an expanded list of telehealth services through the end of the calendar year in which the COVID-19 PHE expires. The existing list adds the following telehealth services covered by Medicare:
- group psychotherapy
- psychological and neuropsychological testing
- domiciliary/rest home/custodial care services
- home visits
- cognitive assessments and care planning services
Under the 2021 PFS Final Rule, CMS provided coverage for telephone-only visits, thus, they will only cover brief (11-20 minute) appointments to determine the necessity of an in-person visit.
What telehealth policy action is still needed?
Congress or CMS needs to take policy action to define the future of telehealth. The Medicare COVID-19 PHE exceptions will expire at the end of the COVID-19 PHE related to:
- virtual prescribing of medications
- treating new patients
- providing services outside of rural areas
- cost-sharing flexibility
- use of non-HIPAA compliant technologies
- providing services across state lines
Overall, patients are highly satisfied with telehealth services. We believe the demand and supply for telehealth will remain even after the end of the COVID-19 PHE. The policy landscape for telehealth is in flux with legislation being proposed at the national and state levels. Before making permanent policy decisions, MedPac released recommendations [pdf] to extend the coverage of telehealth after the PHE to study its effectiveness and impact on health service delivery. This research and other future research will provide the data on which to make these critical policy decisions and address ongoing concerns about inequities in access to telehealth. We will continue to monitor the evolving landscape of telehealth policy.
Editor’s note: for a look at how telehealth may affect provider productivity, check out this article in the May 2021 issue of Medical Care.
Erin Mallonee
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Rebecca McGavin
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Saira Haque