| MedPac Report on Telehealth Services: Insights and Implications |
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Recently, the Medicare Payment Advisory Commission (MedPAC) released a report developed by the American Institutes for Research (AIR), which provides an update to a previous 2023 report examining telehealth’s association with healthcare quality, access and cost in Medicare. Key metrics were developed to measure quality, access, and cost in a setting where both telehealth and in-person visits are available for fee-for-service (FFS) Medicare beneficiaries. The health quality outcomes examined focused on ambulatory care-sensitive hospitalizations and emergency department visits, while access outcomes focus on clinician encounters. The researchers utilized Medicare FFS administrative data to evaluate population-based measures that capture:
- Quality of Care: Risk-adjusted ambulatory care-sensitive hospitalizations and emergency department visits per 1,000 FFS Medicare beneficiaries.
- Access to Care: Clinician encounters per FFS Medicare beneficiary, including a breakdown by provider type.
- Cost of Care: Total cost of care for Part A and Part B services per FFS Medicare beneficiary, with a breakdown of costs by service type.
The study compares data from the second semester (July to December) of 2022 with baseline data from the second semesters (July to December) of 2018 and 2019 (pre-COVID period). As part of their methodology, researchers categorized hospital service areas (HSAs) into low, medium, and high telehealth intensity groupings based on telehealth visits per 1,000 beneficiaries. They also distinguished between behavioral and non-behavioral telehealth visits. Key findings include the following:
- Telehealth and Quality: No significant association was found between telehealth intensity and quality outcomes.
- Telehealth and Access: Higher telehealth intensity was associated with fewer clinician encounters for both behavioral and non-behavioral health.
- Telehealth and Costs: There was evidence suggesting that higher telehealth intensity is associated with a decrease in the total cost of care, although the results were not conclusively definitive.
The researchers concluded with recommendations for improving future studies, such as accounting for patient characteristics like age, race, percentage of dual eligibles, Area Deprivation Index (ADI), and population size. They also highlighted the challenge of separating outcomes for non-behavioral versus behavioral telehealth treatments. However, they noted that if telehealth use continues beyond 2024, absent significant policy changes, it will likely be predominantly used for behavioral health services, simplifying future assessments. For more detailed information, you can access the updated full report developed for MedPAC. |
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Ensuring High-Quality, Cost-Effective Care: BPC's Telehealth Policy Recommendations |
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In mid-July, the Bipartisan Policy Center (BPC) released a press release unveiling their latest issue brief on telehealth policy, titled "Positioning Telehealth Policy to Ensure High-Quality, Cost-Effective Care." The brief builds on BPC’s extensive work, including federal telehealth policy recommendations from 2022 and ongoing research and stakeholder interviews, to provide targeted suggestions for policymakers. The brief emphasizes the transformative potential of telehealth in enhancing healthcare access, improving patient outcomes, and reducing costs. It highlights the need for a robust, bipartisan framework that ensures equitable access to telehealth services, addresses regulatory barriers, and integrates telehealth seamlessly into the broader healthcare system. BPC calls for policymakers to adopt comprehensive strategies that include:
- Expanding broadband access to ensure equitable telehealth availability
- Standardizing telehealth regulations across states to simplify its implementation and usage
- Ensuring telehealth services are reimbursed at rates comparable to in-person visits​
By adopting the broad policy strategies described above, the BPC argues, the U.S. can harness the full benefits of telehealth to deliver high-quality, cost-effective care to all Americans. The issue brief notes that currently Congress is considering bipartisan proposals to maintain current telehealth provisions through 2026, with key committees expressing interest in extending telehealth policies. This makes their findings all the more pertinent. For more information, access the full issue brief. |
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New Lawsuit Challenges California's Telehealth Restrictions
Pacific Legal Foundation (PLF) has filed a federal lawsuit, McBride v. Hawkins, challenging California’s telehealth restrictions that significantly impact patients’ access to specialized medical care. The case involves plaintiffs Shellye Horowitz, who has a rare bleeding disorder, and Dr. Sean McBride, a radiation oncologist. The lawsuit asserts that California’s requirement for out-of-state doctors to be licensed in California to provide telehealth services violates the US Constitution. The central issue is that Shellye Horowitz, who resides in a remote area of California, relies on specialized care from a renowned hemophilia treatment center in Oregon. Due to California’s stringent licensing laws, her Oregon specialists can no longer provide telehealth consultations, forcing Shellye to choose between traveling long distances or forgoing essential medical care. Similarly, Dr. Sean McBride, who practices in New York, uses telehealth to consult with his patients across state lines. However, California’s regulations prevent him from offering virtual consultations to his California patients, jeopardizing their access to necessary pre- and post-treatment care. The lawsuit argues that California’s telehealth restrictions infringe upon the Constitution’s Dormant Commerce Clause and Privileges and Immunities Clause by placing undue burdens on out-of-state physicians and their patients. Additionally, it highlights the First Amendment rights of both doctors and patients to communicate freely without state-imposed barriers.
This lawsuit follows a similar case (Shannon MacDonald, MD, et al v. Otto Sabando) filed in December 2023 by patients in New Jersey who also require specialty care but are hindered by the state’s stringent licensing laws. CCHP extensively covered this case in our January 2024 newsletter, with a follow-up in April 2024.
As these lawsuits gain momentum, any successful outcomes could set a significant legal precedent. This could potentially challenge and dismantle restrictive telehealth regulations in other states, leading to broader access to specialized medical care nationwide. For more information on the lawsuit and its potential impact, see the Pacific Legal Foundation's press release​ on the lawsuit, and read the full text of the plaintiff’s filing. Stay tuned for a more in depth dive into the lawsuit from CCHP in September. |
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CHAI Releases New Assurance Standards Guide
In July 2024, the Coalition for Health AI (CHAI) released its comprehensive "Assurance Standards Guide," aimed at guiding the development and deployment of artificial intelligence (AI) in healthcare. One of the major priorities of AI in healthcare that the guide identifies is enabling patient access to care. Examples of this include implementing virtual care and telemedicine solutions which can be assisted by AI-powered appointment scheduling, mobile applications, AI chatbots, triage systems, and more. This guide serves as a playbook for ensuring ethical and quality standards in AI applications, providing actionable guidance across five key areas: (1) usefulness, usability, and efficacy; (2) fairness, equity, and bias management; (3) safety; (4) transparency and intelligibility; (5) and privacy and security. The guide is the result of a consensus-based approach, incorporating input from a wide range of stakeholders including patient advocates, technology developers, clinicians, data scientists, and bioethicists.
CHAI's Assurance Standards Guide is accompanied by the Assurance Reporting Checklist (ARC), a tool designed for both self-reporting and independent review. The ARC helps developers and evaluators ensure that AI solutions meet best practice standards through detailed evaluation criteria. For more information on the standards in the CHAI Assurance Guide, access the full document. Feedback is being accepted via a public comment form [scroll to bottom of page] ending on September 6, 2024.
Both the CHAI Standards Guide and Checklist comes on the heels of multiple government agencies seeking to regulate AI as it proliferates into the healthcare sector, as well as other sectors. Last year, the Biden administration issued an executive order on AI, requiring tougher safeguards be put in place to protect Americans from the dangers of AI (such as inaccurate data, fraud and cybersecurity vulnerabilities). In July 2024, the Administration announced that several leading AI companies had committed to adhere to principles of safety, security, and trust in their AI developments. This includes Amazon, Anthropic, Google, Inflection, Meta, Microsoft, and OpenAI. These companies have committed to internal and external security testing of their AI systems, sharing best practices, and implementing measures such as watermarking AI-generated content to prevent misuse and deception. The latest Biden Harris Administration factsheet on AI details the actions taken so far to mitigate risks to safety and security posed by AI. This includes technical guidelines, a framework from the National Institute of Standards and Technology, AI testbeds and model evaluation tools, and reporting of results of pilot studies. See the factsheet for a detailed list of all the federal actions on AI. |
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Supreme Court Overturns Chevron Defense: Major Implications for Health Policy Legislation and Rulemaking
The Supreme Court's decision to overturn Chevron USA, Inc. v. Natural Resources Defense Council is poised to profoundly influence health policy legislation and rulemaking. This was highlighted in a recent webinar hosted by the Kaiser Family Foundation (KFF) which included a panel discussion from experts in different facets of health policy, including Medicare and Medicaid, patient and consumer protection and women’s health. Previously, the Chevron decision allowed courts to defer to federal agencies' interpretations of ambiguous laws. However now, because Chevron was overturned, federal health regulations may face increased legal challenges, making agencies more cautious in their rulemaking.
As discussed by the KFF webinar panelists, the Chevron decision may compel Congress to provide more explicit legislative instructions, although achieving consensus on complex health issues might prove difficult. For example, the Centers for Medicare & Medicaid Services (CMS) rely on regulatory authority to expand telehealth services under Medicare, provided these expansions do not contradict existing statutes. With less judicial deference to CMS’s interpretations, policies related to telehealth reimbursement might face increased scrutiny and legal challenges. CMS’ reliance on their regulatory authority when ambiguity exists is exemplified in the most recent 2025 Proposed Physician Fee Schedule where CMS proposes to change the definition of an ‘interactive telecommunication system’ to include audio-only services, despite the absence of explicit legislation that directs them to do so. CMS also has developed a range of communication technology-based service codes that they believe fall outside the scope of telehealth (because they are services that can’t substitute for in-person services), including virtual check-ins, e-visits and remote physiologic monitoring. The fact that a law doesn’t exist that requires CMS to consider these types of services that don’t have an in-person equivalent may also leave them vulnerable to future challenges due to the Chevron decision. Overall, it is thought that the overturning of Chevron could result in delays in policy implementation and create a more fragmented regulatory landscape, affecting both providers and beneficiaries relying on telehealth services, as interpretation will now be left to the courts. To understand the court’s reasoning behind overt turning Chevron, read their decision in Loper Bright Enterprises v. Raimondo. For analysis of its health policy implications, view the KFF virtual event dissecting the decision. Additionally, stay tuned for a CCHP webinar later this month which will further dissect the Loper Bright decision through a telehealth policy lens and provide additional insights. Registration details coming soon! |
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Latest Policy Developments in CCHP’s Telehealth Policy Finder and Policy Trends Map
CCHP’s Telehealth Policy Finder look-up tool and Policy Trend Maps were updated throughout the past month based on the latest information from our ongoing state telehealth policy tracking. The latest states to be updated include Connecticut, Delaware, Illinois, Kentucky, Nebraska, North Carolina, Oregon, and South Dakota.
Over the past month, multiple states made changes to their telehealth policies in an array of policy areas, including their Medicaid programs, professional regulations, and cross-state licensing. Highlighted changes from this group of states include:
- CONNECTICUT: Passed HB 5198 which repeals temporary telehealth expansions in all parts of law. However, it made certain elements permanent, including prohibiting payers from reducing reimbursement amounts to telehealth providers solely because services were not delivered in person. The bill also permanently removes the explicit exclusion of audio-only telephone calls from the definition of telehealth and establishes various provider practice requirements. Additionally, allowances for out-of-state providers to deliver mental or behavioral health care are now subject to registration and other specified conditions. CT Medicaid also released a bulletin specifying that Department of Children and Families (DCF) providers can be reimbursed for services performed via telehealth when billed with appropriate codes. Another bulletin also identified two telephone evaluation/management codes that are now eligible for reimbursement in the Person-Centered Medical Home Program. Finally, Connecticut’s legislature passed HB 5058 which enacted the Nurse Licensure Compact and HB 5197 which enacted the Social Work Licensure Compact.
- ILLINOIS: Passed SB 3414 which requires that by January 1, 2026, insurers provide coverage for continuous glucose monitors, related supplies and training if certain requirements are met, such as a patient be diagnosed with diabetes mellitus. The Medical Assistance program is also required to adopt rules to provide coverage of continuous glucose monitors. See the bill text for additional requirements.
- KENTUCKY: Passed HB 56 to enact the Social Work Compact. The Compact allows regulated social workers to be granted a licensure privilege to practice in other states that have enacted the Social Work Compact. Note that the Compact is new and not yet issuing licenses. The implementation process of the compact will take 12 to 24 months before multistate license are able to be issued.
- NEBRASKA: Nebraska Medicaid issued a bulletin to implement LB 857, which requires Medicaid coverage of continuous glucose monitoring devices for fee-for-service members with diabetes mellitus who meet certain criteria. The bulletin indicates that the initial authorization period is six months and can be renewed on a yearly basis. Supplies will be provided for 30 days or up to 90 days at a time.
- NORTH CAROLINA: North Carolina Medicaid issued a reminder for ophthalmologists, optometrists and opticians that specifies that medical and routine eye exams and visual aids are not covered under the program’s telehealth policy. Therefore, providers may not utilize telehealth modalities when providing eye exams.
- SOUTH DAKOTA: Updated their Telemedicine and Audio-Only Services Manual to add to their list of eligible distant site providers: Behavior Analyst, Board-Certified Assistant Behavior Analyst (BCaBA), and Registered Behavior Technician (RBT). South Dakota also joined the Psychology Interjurisdictional Compact (PSYPACT).
Given the nuanced and varied approaches states are taking with their telehealth policies, please reference CCHP’s telehealth Policy Finder to link to additional details and access each states’ policies in their entirety. |
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Telehealth in New York State
A new white paper, titled "Ensuring Long-Term Equitable Access to Telehealth in New York State: Opportunities and Challenges," by Manatt Health, funded by the New York Health Foundation outlines a policy roadmap to enhance and sustain telehealth services across New York state (NYS). The white paper opens with a background of telehealth policy in NYS, suggesting that NYS has been a leader in expanding telehealth access, removing restrictions, and broadening policies for Medicaid and state-regulated commercial plans. This expansion facilitated innovative programs like pediatric teledentistry, telehealth consultations in non-traditional settings, and rapid-access virtual health services. While NYS has maintained many pandemic-era policies, opportunities exist to further strengthen and enshrine these policies. Key recommendations include:
- Permanent Payment Parity: Establishing permanent payment parity for virtual visits across all payers to ensure accessibility and encourage provider investment. New York has extended parity through April 2026, supporting ongoing telehealth services and allowing further study of its impact. However, providers may need more reassurance that payment parity will become permanent for additional investments in telehealth care models.
- Payment Parity for Audio-Only Visits: Implementing payment parity for audio-only visits across all payers, including Medicaid-specific requirements. This ensures access for low-income populations lacking video capabilities or local providers.
- Equitable Reimbursement for Federally Qualified Health Centers (FQHCs): Providing full reimbursement rates for remote visits to support patient access and provider retention. Unlike other states, New York's reduced reimbursement based on patient and provider locations may force FQHCs to limit or discontinue telehealth services, affecting an already strained system.
- Cross-State Licensure: Developing a New York-specific approach to cross-state licensure to address provider shortages and maintain continuity of care. This could include a special-purpose telehealth registry to allow a broad range of providers to deliver telehealth services to New York residents.
As other states adapt their telehealth policies for a post-COVID world, state-specific reports on telehealth like this NYS white paper are increasingly common and can offer insights for other states as well. For more details on the Manatt findings and recommendations, read the full white paper. |
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Telemedicine Referrals for Opioid Use Disorder: A Promising Alternative
In a new study slated to publish in the Journal of Substance Use and Addiction Treatment October 2024 issue, researchers explored the effectiveness of telemedicine referrals for patients with opioid use disorder (OUD) compared to traditional emergency department (ED) referrals. The research focused on the Medication for Addiction Treatment and Electronic Referrals (MATTERS) Network, which collects extensive patient data, including demographics, visit reasons, medical and mental health history, and prior OUD treatment. The study aimed to compare initial outpatient clinic appointment attendance and 30-day treatment retention rates between patients referred from EDs and those referred via telemedicine.
From October 2020 to September 2022, the MATTERS Network made 1,349 referrals, with 39.7% originating from EDs and 47.8% from telemedicine. Findings revealed that patients referred through telemedicine were significantly more likely to attend their initial clinic appointments and remain in treatment for 30 days compared to those referred from EDs. Specifically, telemedicine referrals resulted in a 1.64 times higher attendance rate at initial clinic visits and a 2.59 times higher retention rate at 30 days. These results suggest that telemedicine is a viable and effective alternative for initiating and retaining patients in OUD treatment, highlighting the need for further development of telemedicine programs to support addiction treatment. To learn more about the researcher’s methods and findings, see the full study. |
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What’s New at CCHP this Month?
CCHP is continually working to create helpful informational content to keep those interested in telehealth and related policies up to date via our policy finder, informational factsheets, webinars, reports and email blasts. As you may already be aware, CCHP regularly distributes a single topic specific email every Tuesday titled “Telehealth Tuesdays”. If you are not yet on our distribution list to receive these emails, and would like to be added, you can do so by registering on the CCHP website.
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Quick links to recently curated and featured insightful topics in our Telehealth Tuesday email blasts:
AUGUST 26: CCHP Release of New Licensure Resources: New Policy Trend Map, Webinar and Factsheet covering new CCHP resources related to cross-state practice via telehealth based on the extensive technical assistance questions CCHP commonly received on the topic. For more information on the new resources, see the next section on the latest resources developed by CCHP.
JULY 29: Interstate Licensure Compacts: Updates and Overview covering the proliferation of licensure compacts for various professions, and highlighting the Health Resources and Services Administration’s new investment in the Social Work Licensure Compact.
JULY 23: POS Non-Facility Rate Payment and Modifiers Clarifications covering a Change Request to the CMS Manual System that specifies that services billed with place of service code 10 (when the patient is at home) will be paid at the non-facility rate, and services with POS 02 (when the patient is not at home, but instead at a provider’s office or medical facility) will pay the facility rate. It also specifies that services should be billed with the appropriate 93 (for audio-only) or 95 (for live video) modifiers.
JULY 18: Proposed CY 2025 Physician Fee Schedule (PFS) – A Drilldown on the Telehealth Proposals, a special email release providing an in-depth analysis of the telehealth components contained in the proposed PFS and announcing the release of CCHP’s factsheet on the telehealth proposals.
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In addition to our featured topics in CCHP’s Telehealth Tuesday emails we have also released the following valuable resources:
- A factsheet that drills down on the telehealth elements of the proposed Calendar Year 2025 Physician Fee Schedule, along with a special email announcing the factsheet, and providing a summary of its contents. It covers how CMS plans to address telehealth in the wake of the potential end of the COVID telehealth flexibilities in Medicare.
- CCHP also created a short video to discuss the PFS proposals.
- A factsheet that summarizes out-of-state licensure policies, identifying states that have limited licensure exceptions, telehealth license or registration processes, as well as those that participate in an interstate licensure compact.
- CCHP also added a trend map that reflects states with out-of-state provider policies and published a webinar on cross-state licensure and compacts.
- A timeline of how the policy related to telehealth prescribing of controlled substances has evolved since it was initially regulated in 2008 up until today.
To stay up to date on all the latest CCHP releases, view our website’s Resources page which catalogs all of CCHP’s resources. |
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FEDERAL LEGISLATION
Supporting Patient Education and Knowledge Act of 2023 (“SPEAK Act of 2023”)
HR 6033 (Rep. Steel R-CA) – Requires the Secretary of Health and Human Services (HHS) to establish a task force to improve access to health care information technology for non-English speakers. Their tasks would include assessing current barriers to health information technology services, including telehealth platforms and patient portals, for people with limited English proficiency, among other items. Additionally, HHS would be required to publish, publicize, and maintain a website for the purposes of informing health care and technology providers about best practices for connecting people with limited English proficiency to health care information technology services. The website shall provide guidance and resources, identifying best practices in, among other things, facilitating and integrating use of interpreters during telehealth sessions as well as providing accessible instructions on how to access telehealth platforms for people with limited English proficiency. (Status: 6/12/24 – Committee consideration and mark-up held)
340B Affording Care for Communities and Ensuring a Strong Safety-net Act” or the “340B ACCESS Act”
HR 8574 (Rep. Buschon R-IN) - Provides reforms for the 340B drug pricing program (a government program that requires manufacturers to sell outpatient drugs at a discounted rate to eligible health care organizations). Specifies that a prescription for a covered outpatient drug resulting from a heath care service furnished through telehealth, telemedicine or other remote health care arrangements do not qualify for the pricing unless it is from a specific type of covered entity (such as a sole community hospital) and the entity has conducted an in-person examination of the individual within the 6-month time immediately preceding the health care service resulting in the prescription or order for the drug. (Status: 5/31/24 – Referred to the Subcommittee on Health)
Expanding Remote Monitoring Access Act
HR 5394 (Rep. Balderson R-OH) - Requires that the Secretary of Health and Human Services ensures that remote monitoring services are payable for a minimum of two days for data collection over a 30-day period, regardless of whether the individual receiving such services has been diagnosed with, or is suspected of having, COVID-19. The requirements would last two years after the date of enactment of the bill. HR 5394 also requires a report to Congress that summarizes and analyzes remote monitoring services for the two-year period the bill is in effect. See bill for details regarding the report. (Status: 5/16/24 – Forwarded by Subcommittee to Full Committee (Amended) by Voice Vote)
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STATE LEGISLATION
ALASKA
SB 91 – Specifies that a physician licensed in another state or an out-of-state member of a physician’s multidisciplinary care team may provide health care services through telehealth to a patient located in Alaska if the services are not reasonably available in the state. See bill for additional requirements. (Status: 7/19/24 – Became law without Governor’s signature. Effective 10/16/24)
DELAWARE
HB 333 - This Act creates the Delaware Artificial Intelligence ("AI") Commission. This Commission shall be tasked with making recommendations to the General Assembly and Department of Technology and Information on AI utilization and safety within the State of Delaware. (Status: 7/17/24 – Signed by Governor)
DISTRICT OF COLUMBIA
B 25-0545 – Specifies that a health professional in the District may provide telehealth services to a District resident if its within their standard scope of practice and not otherwise prohibited by law or regulation. The law states that a practitioner-patient or practitioner-client relationship may be established through telehealth provided that the Mayor may issue additional requirements including a requirement for an initial in-person physical examination. The new law also allows out-of-state providers to see clients or patients in the state if they have an existing relationship and the client/patient are temporarily present in the District or are a resident and the telehealth service provided does not exceed 120 days or a longer period of time as determined by the mayor. (Status: 7/19/24 – Became law. Effective July 19, 2024)
ILLINOIS
SB 3414 - Provides that a group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed before January 1, 2026 shall provide coverage for medically necessary continuous glucose monitors for individuals who are diagnosed with any form of diabetes mellitus and require insulin for the management of their diabetes, as well as any related supplies, and training. (Status: 7/1/24 –Governor approved. Became a Public Act)
MASSACHUSETTS
H 2254 - Explicitly allows a physician to provide healthcare services via telehealth if certain conditions are met and the standard of care conforms to the standards of in person care and any applicable federal and state health information privacy, security and informed consent standards. (Status: 7/18/24 –Accompanied a study order, see H4854)
OHIO
SB 28 – Enacts the Physician Assistant Licensure Compact in Ohio. (Status: 7/17/24 –Sent to Governor. Will become effective 10/24/24) |
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