If you’re like me, or about 40 percent of Americans (probably more by now), you’ve had at least one telehealth visit sometime during the pandemic. I was fortunate enough that my insurance provider covered the visits, but this isn’t usually the case for Medicare patients because hardly any of them qualify for telehealth coverage. In order to reverse that problem permanently, Congress needs to act. On November 5, Reps. Lisa Blunt Rochester, Buddy Carter, and Cathy McMorris Rodgers did just that, introducing the bipartisan H.R. 8727, the Telehealth Modernization Act. The bill, which would finally enable the future of American healthcare to unfold, is the identical House companion to Sen. Lamar Alexander’s legislation, which collected digital health leaders Sen. Brian Schatz and Sen. Roger Wicker as key cosponsors.
Medicare is the nation’s largest insurer, covering more than $750 billion worth of healthcare services each year. Medicare coverage decisions influence the private insurance market because its rules have such a wide-ranging impact. In fact, healthcare vendors and providers often use the payment codes that correspond to Medicare’s coverage to categorize private claims too. Medicare rules and decisions are a centerpiece of healthcare policy affecting all Americans. But private insurers clearly outpaced Medicare in covering live audio and video (telehealth) visits. The U.S. Department of Health and Human Services’ (HHS’) Centers for Medicare and Medicaid Services (CMS) makes overarching Medicare coverage decisions with input from stakeholders, but it is generally prohibited from covering those services. More specifically, the Medicare statute that governs CMS only allows Medicare to cover telehealth visits when the beneficiary is at a “qualified originating site” (generally, another doctor’s office, not at the patient’s home or anywhere else) and in a “rural health professional shortage area,” among other restrictions. As a result, telehealth is, with small exceptions, unavailable to Medicare beneficiaries. Let that sink in for a minute . . . you can make a down payment on a home and agree to a mortgage from your phone, but you can’t speak with your doctor? It doesn’t add up.
Now, in the waning days of 2020, and the middle of a pandemic, HHS has temporarily waived the originating site and geographic restrictions on telehealth coverage with temporary authority from Congress, which expires at the end of the public health emergency (PHE). The move helped caregivers treat their patients while limiting the spread of disease, enabling them to see “50 to 175 times the number of patients via telehealth” than before the pandemic. So, what happens after the PHE expires? That’s where the Telehealth Modernization Act comes in. The bill takes an aggressive approach, adding “any site at which the eligible telehealth individual is located at the time the service is furnished” as a qualified originating site and removing geographic restrictions altogether. Other measures come close, adding “the home of an individual” to the list. This is a big step forward, but “any site” includes important patient populations that “the home of individual” leaves out, including:
People who lack access to broadband at home and have to access remote care elsewhere (about 41 percent of Medicare beneficiaries lack access to a computer at home with high-speed internet and about 25 percent have neither a smartphone nor a landline broadband connection);
People who don’t have a fixed address (either they’re experiencing homeless or between homes for any number of reasons); and
People who are members of at-risk, including LGBTQIA, communities or have unstable environments at home (either they’re living in an environment that is hostile to or impedes their medical needs or otherwise need to be away from family or other co-habitants to receive care).
Beyond the pandemic, sidelining the “originating site” and geographic restrictions will help address three serious concerns on policymakers’ minds: 1) inequitable access to care for rural Americans, who are having to drive longer distances to see caregivers as rural health centers continue to shutter; 2) inequitable access to care for ethnic minorities, socioeconomically disadvantaged, and marginalized communities; and 3) the expanding physician shortage, which could balloon to nearly 122,000 by 2032. As policymakers are starting to realize now, the case has been made for telehealth. The Telehealth Modernization Act paves the way for this, not by requiring CMS to cover telehealth, but by removing barriers currently in the way that make it impossible for CMS to do so. It is the right policy at the right time and a growing coalition is urging Congress to advance the bill as soon as possible.