Womble Bond Dickinson provide insight into telehealth during the pandemic see more
- Telehealth greatly expanded during the COVID-19 pandemic, in large part due to regulatory waivers. Those regulatory waivers aren’t permanent, but lawmakers are evaluating ways to permanently expand some aspects of telehealth coverage.
- While the HHS OIG recognizes the importance that telehealth plays in our healthcare system and will continue to evaluate new telehealth policies and technologies so as to improve care, it will also strive to ensure that they are not compromised by fraud, abuse, and misuse.
- Through recent telehealth policies and funding, the government is working to improve healthcare equity and resources for telehealth.
While the COVID-19 pandemic remains a public health and economic concern, companies are adapting and adjusting, finding new and better ways to do business moving forward. Womble Bond Dickinson is taking a comprehensive look at this new Opportunity Economy from a wide range of viewpoints. Recently, Womble Bond Dickinson attorneys Alissa Fleming and Toni Peck explored the pandemic-inspired expansion of telehealth services and how such measures can benefit patients and providers alike moving forward. They recently spoke to Womble Bond Dickinson attorney Mark Henriques on an episode of the “In-house Roundhouse” podcast, and the article below is based on that conversation.
The telehealth boom during the COVID-19 pandemic impacted nearly every American. Changes made during the public health emergency promise to permanently transform the delivery and availability of healthcare. While these changes were made in rapid response to the pandemic, providers and patients alike discovered that telehealth—providing healthcare remotely via technology—offers advantages and efficiencies that make sense to continue even as the pandemic ends.
Healthcare is perhaps the most highly regulated sector of the economy, so extending telehealth post-pandemic will require regulatory reform as well as consumer demand.
The State of Telehealth in the Late-Stage Pandemic
Telehealth isn’t a new idea. As Peck said, “Prior to the pandemic, there was an interest from providers and patients, but there were restrictions and limitations that kept telehealth from being as popular as it currently is.”
For example, providers faced geographic restrictions for where they could serve patients. Only certain types of technology could be used. And only a limited number of telehealth services were eligible for reimbursement from Medicare, Medicaid and private payors.
A study published in JAMA Network Open found that telehealth services grew by 1,000 percent in March 2020 and 4,000 percent in April 2020, with in-person visits declining 23 percent and 52 percent respectively. Those numbers have evened out somewhat, Peck said, but telehealth use remains much more popular than it was pre-pandemic.
“One of the biggest things that has changed has been patient and provider attitudes—we’re more willing to use it,” Peck said.
Also, federal and state governments have lifted many of the previous geographic restrictions temporarily. Technology requirements have been relaxed temporarily to allow for the inclusion of Zoom, FaceTime, and other popular platforms. More services now can be reimbursed, prescription restrictions have been relaxed, and licensure requirements by state medical boards have been eased temporarily.
“Telehealth has been crucial in the past 18 months, especially in championing healthcare equity,” Peck said. “We are better able to reach underserved populations, including rural populations, with telemedicine.”
Not surprisingly, investors have taken notice. Venture capital funding for telehealth reached $15 billion in the first half of 2021, up from $6.3 billion in the first half of 2020.
The rapid increase in telehealth adoption wouldn’t have been possible without regulatory streamlining that came in response to the public health emergency.
“Before the pandemic, telehealth only covered about 100 service areas, primarily those serving beneficiaries in rural areas,” Fleming said. But in early 2020, the Centers for Medicare and Medicaid Services (CMS) expanded Medicare coverage by adding 140 additional services, regardless of location. This includes ER visits, occupational/physical therapy, hospital discharge day issues and other non-critical care services. Also, a much broader range of providers now may provide these services via telehealth.
“This expansion of Medicare and Medicaid coverage helped to spawn payment for telehealth by private insurance payers,” Fleming said. “In allowing this expansion, the government acknowledged the critical role telehealth plays in expanding healthcare access.”
What’s Next in Telehealth?
But while telehealth has played a critical role in expanding healthcare access during the pandemic, the scope of the relaxed regulations was not intended to be permanent. So when do waivers expire and will they be continued?
Fleming explained that currently, the waivers will stay in effect through the end of the public health emergency or the end of the year. “With the Delta surge and the additional challenges that have come this summer and fall, there has been no further extension of the timetable, but that’s not to say there won’t be,” she said.
Such an extension may have a broad base of support, but it won’t necessarily happen automatically or without additional change.
Over the past several years, federal regulators have scrutinized telehealth arrangements, with a particular concern about fraud and abuse. The pandemic waivers reduced red tape, but federal regulators remain concerned about potential fraud and abuse issues.
“It’s not as easy as we might hope to permanently remove some of the regulatory requirements relaxed during the pandemic,” Fleming said. “Depending on the regulatory concerns, we may not see it expanded on such a broad base as we are seeing during the public health emergency.”
Peck also noted that some waiver expansions will require Congressional action, not just administrative changes.
States also will play a role in the continued, permanent expansion of healthcare. Generally, state regulatory schemes are concerned with licensure and scope of practice issues, while federal regulations deal primarily with reimbursement and the prevention of healthcare fraud, abuse, and misuse. So reforming telehealth regulations will require both federal and state action.
“Some states have already made changes to their licensure rules,” Fleming said. For example, Florida has created a specific telehealth license which allows out-of-state providers to become licensed to provide telehealth services in the state.
“Hopefully, other states will follow suit. It could create a solution to the lack of certain specialists in particular areas,” she said.
The Biden Administration has been busy in addressing telehealth concerns. In August 2021, the Administration announced a $19 million investment in telehealth, going to 36 recipients serving rural areas and underserved communities. This grant money will fund:
- Telehealth technology-enabled learning programs., building mentoring capacity in underserved areas.
- Twelve regional and two national telehealth resource centers. These centers will provide resources, information and education on telehealth to healthcare providers.
- Evidence-based direct-to-consumer telehealth networks. Bypasses some of the service restrictions.
- The creation of telehealth centers of excellence programs. These centers will assess and improve services in rural and underserved areas with high disease and poverty rates. This work will include piloting new services and publishing research.
“This award money is exciting because it provides funding for the growth of the actual telehealth structure,” Fleming said.
Looking Ahead: The Near-Future of Telehealth
Of course, expanded access to telehealth services requires that patients have high-speed broadband internet connections.
“We assume that if telehealth exists that everyone can use it, and that simply is not the case,” Fleming said. Many remote rural areas, in particular, struggle with broadband access. The sweeping federal Infrastructure Investment and Jobs Act seeks to address this disparity by providing $65 billion to expand broadband infrastructure.
“The Infrastructure Investment and Jobs Act also has an expansion of Medicare for telehealth, especially for mental health,” Peck said. “A lot of literature coming out of the pandemic shows that the need for mental health has increased greatly, and telehealth is a good platform for mental health care.”
In July, CMS published its 2022 proposed physician fee schedule. The proposal includes extending telehealth services for certain mental health care through 2023 or even permanently. Fleming said this will remove many barriers for receiving mental health care.
“Studies have shown that over a third of the population lives in an area without mental health providers. There’s a real shortage of providers in this field,” she said.
Another change, in response to the opioid epidemic, is that CMS is proposing that the home can be a site for treating substance abuse disorders.
Finally, CMS is asking providers for data about Category 3 telehealth services. This class of services was created during the pandemic to designate healthcare services that can be provided temporarily via telehealth. CMS is now looking at whether there is sufficient evidence to support permanent telehealth coverage of those services.
“Reimbursement is critical because nobody is going to provide services if they aren’t paid for them,” Peck said.
Reimbursement is one of several complex issues that must be considered during any permanent extension of telehealth exemptions. For example, Peck said that if a matter can be resolved in a five-minute phone call, should it be reimbursed at the same rate as an in-office visit? Other challenges remain, including the low rates of telehealth adoption in low-income and low English proficiency communities.
But even with the challenges, Peck and Fleming believe telehealth will remain an important platform for delivering healthcare services, even after the COVID-19 pandemic recedes.
“All in all, if there’s one thing the pandemic taught us, it’s that telehealth is a viable option,” Peck said. “Perhaps not by itself—we need to look at how telehealth and in-office visits can work together. But telehealth is a way to have a more efficient, equal healthcare system.”
More than $19 million in grants to several key connected health projects see more
The federal government is investing more than $19 million in key telehealth initiatives, including the National Consortium of Telehealth Resource Centers (TRCs) and Telehealth Centers of Excellence (COE) program.
Some 36 awards are being distributed by the Health and Human Services Department through the Health Resources and Services Administration’s Office for the Advancement of Telehealth to some of the nation’s highest-profile connected health projects. The investments are aimed at strengthening programs and supporting innovation in areas that have seen record adoption and growth during the pandemic.
“Telehealth expands access to care and is a vital tool for improving health equity by providing timely clinical assessment and treatment for our most vulnerable populations,” HRSA Acting Administrator Diana Espinosa said in a press release issued this morning. “This funding will help drive the innovation necessary to build clinical networks, educational opportunities, and trusted resources to further advance telehealth.”
The TRC consortium, which consists of 12 regional and two national centers, is getting $4.55 million – or $325,000 per site - to bolster and expand their efforts. The TRCs, which provide a wide range of guidance and resources, have seen heavy traffic over the past year and a half as healthcare providers and other organizations have adopted telehealth to deal with the COVID-19 crisis.
The Telehealth COE program, meanwhile, is getting $6.5 million to expand services and strategies aimed at improving access and outcomes in underserved parts of the country that deal with high chronic care needs and poverty, and to serve as incubators for new telehealth ideas. Located in academic medical centers, COEs are seen as national models for evidence-based programs and strategies that promote best practices.
In 2017, the Medical University of South Carolina (MUSC) and University of Mississippi Medical Center (UMMC) were designated Telehealth Centers of Excellence. The award is being split between the two programs.
The Evidence-Based Direct-to-Consumer Telehealth Network Program (EB-TNP) is getting roughly $3.8 million to bolster its DTC telehealth efforts. Those awards are being issued to 11 organizations: HealthHIE Georgia, Cornerstone Whole Healthcare in Idaho, Drake University in Iowa, the University of Kansas Medical Center Research Institute, Baptist Health Foundation Corbin in Kentucky, MaineHealth, UMMC, Lester E. Cox Medical University in Missouri, the Ben Archer Health Center in New Mexico, East Carolina University in North Carolina and Texas A&M University.
Finally, the Telehealth Technology-Enabled Learning Program (TTELP) is getting about $4.28 million to “help specialists at academic medical centers provide training and support to primary care providers in rural, frontier, and other underserved areas to help treat patients with complex conditions ranging from long COVID to substance use disorders in their communities.”
Those awards are going to nine organizations: Community Health Center in Connecticut, the American Academy of Pediatrics in Illinois, the University of Kansas Medical Center Research Institute, Medical Care Development in Maine, the JSI Research and Training Institute in Massachusetts, President and Fellows of Harvard College in Massachusetts, the University of New Mexico, Oregon Health & Science University and the Puerto Rico Science, Technology & Research Trust.
Helping patients stay out of hospital, recover faster see more
Prisma Health is taking key elements of inpatient care into patients’ homes to help them stay out of the hospital under a new program for the Midlands called Home Recovery Care.
The model has been used at Prisma Health hospitals in the Upstate, according to a news release.
For patients under care through Prisma Health Richland Hospital, the organization partners with Nashville, Tenn.-based Contessa to deliver the service at its third site, the news release said.
The program launched at Greenville Memorial Hospital in 2019 and expanded to Oconee Memorial Hospital last year. In the Upstate, the program has a 90% acceptance rate and an average patient satisfaction score of 98%, according to the release.
Prisma Health was one of the first health systems approved to provide Home Recovery Care to Medicare fee-for-service patients under the Center for Medicare and Medicaid Services’ Hospitals Without Walls waiver, the release said. Programs that encourage hospitals to find healthy ways to stay out of emergency rooms and hospital rooms have been part of Medicare/Medicaid rules for years, with the COVID-19 pandemic spurring more efforts.
“Prisma Health has had great success with the program in the Upstate, and we are thrilled to provide this level of home care to more South Carolinians by adding it at Richland,” Bo Cofield, Prisma Health Richland Hospital CEO, said in the release. “The COVID-19 pandemic reinforced that going beyond the walls of the traditional hospital setting often gives our patients a better option for acute-level health care. Home Recovery Care was in place before the pandemic, but it is now gaining momentum. We believe this kind of service is essential to the care of our patients and is an important component of health care.”
Home recovery is more satisfying for patients and costs less than traditional recovery in a hospital, according to the release.
The care is for patients with acute, non-life-threatening medical conditions. Roughly 150 diagnoses are considered eligible for the service and range from congestive heart failure and pneumonia to dehydration, cellulitis and urinary tract infections. Patients must be evaluated by a Prisma Health doctor to determine if their conditions can be safely treated in the home instead of a standard hospital environment, according to the release.
The program includes 24-hour access to a recovery care coordinator and continual monitoring for up to 30 days, the release said. The in-home work is done by Prisma Health’s home-health registered nurses and by physician consultation utilizing telehealth.
“Since we launched the program, we have served 300 patients and saved patients from being hospitalized for 1,000 additional inpatient days,” Angela Orsky, vice president of post-acute services at Prisma Health, said in the release. “Our patient likelihood to recommend scores are 100, and we are exceeding all our quality targets. Our home health clinicians in partnership with our hospitalists have exceled in the ability to care for complex patients safely in their homes.”
Greenwood Genetic Center project receives grant to expand access for genetics services see more
The Greenwood Genetic Center (GGC), through the Self Regional Healthcare Foundation, has been awarded a grant of $899,000 from The Duke Endowment for 'Genetics Access for All,' a project to expand access to genetics services for patients and providers.
"In this current era of genomic medicine, there is an increasing demand for clinical genetics services, but our workforce is insufficient to meet this demand, and our current work flows are inefficient," said Mike Lyons, MD, Director of Clinical Services at GGC and lead on the funded project. "This leads to families facing long waits to be evaluated and tested, and subsequent delays in managing and treating their child's condition."
GGC has provided clinical genetics services since 1974; however, with the increase in demand for services, and inability of genetics training programs to keep up with the ensuing workforce demand, patients often wait for six months or longer to be seen.
"This is not just a GGC issue. Genetics clinics around the country are facing wait times that are as long or longer than ours," said Steve Skinner, MD, GGC Director. "And we have found that as genomic technology has been evolving at such a rapid pace, many non-genetics providers do not feel comfortable ordering and interpreting genetic tests on their own."
'Genetics Access for All' proposes a new standard of genetics care by optimizing access for patients and employing a new system of communication to transform how non-genetics providers engage with genetics providers in order to better manage their patients.
In 2019, GGC and the Medical University of South Carolina (MUSC) signed an affiliation agreement with the goal of improving access to genetic services for patients across SC.
One initiative that has grown out of this affiliation is a pilot project with the MUSC Center for Telehealth to develop an electronic consult (e-consult) system for genetics referrals. The project initially offered the option only to a limited number of referring providers in the MUSC system. Funding from The Duke Endowment will allow that project to expand on a much larger scale.
During the first year of the funded project, GGC will implement e-consults through an online platform to allow non-genetics providers to upload patient information, and receive clinical impressions and testing recommendations within two business days. E-consults will help avoid unnecessary referrals, improve communication with non-genetic providers, and enhance efficiency by decreasing the amount of time needed for in-person and telemedicine visits.
In year two, GGC plans to expand the concept to provide electronic patient visits (e-visits) allowing patients to upload their information electronically and quickly receive clinical feedback and recommendations. The goal of e-visits is not to replace in-person or telegenetics visits, but to provide another care option that improves communication with and access for patients.
Lyons says that the ultimate goal of this project is to change the model of genetics care from a long diagnostic odyssey to a more efficient system that decreases unnecessary referrals, expedites diagnoses, and decreases wait times for appointments.
"Through e-consults, we'll be able to more quickly identify patients who need genetic testing and facilitate the appropriate testing," he said. "A rapid diagnosis will allow for more timely and precise management and treatment for all patients impacted by a genetic disorder."
GGC expects to see significant improvements in patient care as the project expands. "Our goals are to complete 50 outpatient and 25 inpatient e-consults and 25 e-visits per month by the end of the grant cycle," said Lyons. "We anticipate this project to dramatically improve wait times for all types of visits, and hope that our success can be translated into a new model for genetics care in clinics nationwide."
About Greenwood Genetic Center
The Greenwood Genetic Center (GGC), founded in 1974, is a nonprofit organization advancing the field of medical genetics and caring for families impacted by genetic disease and birth defects. At its home campus in Greenwood, South Carolina, a talented team of physicians and scientists provides clinical genetic services, diagnostic laboratory testing, educational programs and resources, and research in the field of medical genetics. GGC’s faculty and staff are committed to the goal of developing preventive and curative therapies for the individuals and families they serve. GGC extends its reach as a resource to all residents of South Carolina with satellite offices in Charleston, Columbia, Florence and Greenville. For more information about GGC please visit www.ggc.org.
About The Duke Endowment
Based in Charlotte and established in 1924 by industrialist and philanthropist James B. Duke, The Duke Endowment is a private foundation that strengthens communities in North Carolina and South Carolina by nurturing children, promoting health, educating minds and enriching spirits. Since its founding, it has distributed more than $4 billion in grants. The Endowment shares a name with Duke University and Duke Energy, but all are separate organizations.
MUSC continues advances in telehealth see more
The Medical University of South Carolina has received a $3.6 million grant to support the development of a national telehealth research network.
As opposed to supporting a specific clinical research study, the grant seeks to establish an easily accessible support structure around telehealth research, including tools, resources, collaboration, education and advocacy materials to anyone across the country who wants to study telehealth programs.
“We expect this network to become the preeminent source for evidence-based policy and outcomes data,” said Brook Yeager McSwain, health policy consultant for the project and manager of the S.C. Children’s Telehealth Collaborative, in a news release. “Our national and state legislators have seen the benefits of telehealth for certain populations and regions. We have to demonstrate to them that this works across the country and has the potential to dramatically impact health care delivery models.”
The five-year National Institutes of Health grant builds on work already underway as part of the Supporting Pediatric Research on Outcomes and Utilization of Telehealth project, known as Sprout. The grant will support telehealth research efforts, metric development, identification of best practices and the development of collaborative policy and advocacy materials across the country.
Sprout is a network of institutions and pediatric providers operating within the American Academy of Pediatrics, which is a sub-awardee of the grant. The other sub-awarded institutions are the University of Colorado – Children’s Hospital Colorado, Children’s Hospital of Philadelphia and Mercy Hospital in St. Louis.
“This is a huge step forward in the development of safe and impactful telehealth programs across the country,” said Dr. S. David McSwain, the primary investigator for the NIH grant, in the release. “Academic research into the real impact of telehealth services is a critical component of developing and growing programs with the greatest potential to improve our health care system.”
In 2015, McSwain, who is also an MUSC Children’s Health physician, MUSC chief medical information officer and associate professor of pediatric critical care, collaborated with a small group of pediatric physicians across the country to form Sprout, which has since completed and published the nation’s first broad assessment of pediatric telehealth infrastructure across the country.
The grant is a Collaborative Innovation award through the National Center for the Advancement of Translational Science. The program will operate in collaboration with Clinical and Translational Science Awardsites across the country to facilitate research development and support telehealth researchers to develop projects and find funding.
MUSC receives grant for expansion of telehealth program see more
The Medical University of South Carolina (MUSC) palliative care program has received a $1,278,000 grant from The Duke Endowment to create a statewide, palliative care telehealth program.
Providing end of life and comfort care to those in need, especially for the state’s most vulnerable and rural populations, is the primary aim of the new effort. Program leadership expects not only an improvement to accessibility for this kind of care, but also potential cost savings to individual patients and the system as a whole. Click for full details.