Lawmakers Mull Telehealth Quality, Reimbursement As Extension Deadline Looms

Lawmakers lauded the benefits of telehealth during a hearing Wednesday, but House members also raised questions about cost, quality and access that still need to be answered as a year-end deadline looms.

As a December deadline draws closer, legislators are working to hash out details about extending or making pandemic-era telehealth flexibilities in Medicare permanent. 

During an hours-long House Energy and Commerce subcommittee hearing, lawmakers considered 15 different legislative proposals surrounding telehelath access, noting changes in Medicare will impact decisions of private insurers.

“There’s an urgent need to extend these flexibilities because it’s going to run out,” said Rep. Anna Eshoo, D-Calif. “We need to take action on this.” 

During the public health emergency, regulators loosened some telehealth rules, like allowing beneficiaries to receive virtual care in their homes, eliminating geographic restrictions and expanding audio-only telehealth services. 

While some changes were made permanent, others are set to expire at the end of the year — which could spell a crisis for providers and patients who are used to the flexibilities, witnesses at the hearing told lawmakers.

“There’s an urgent need to extend these flexibilities because it’s going to run out,” said Rep. Anna Eshoo, D-Calif. “We need to take action on this.” 

Some policy questions surrounding telehealth still linger, including how to ensure quality care and continued access to in-person services, as well as how much to pay providers for telehealth. 

“The looming deadline gives us a chance to examine long-term telehealth solutions that can drive innovation in healthcare through greater delivery,” said Rep. Brett Guthrie, R-Ky.

How much should Medicare pay for telehealth?

Telehealth does increase healthcare spending modestly, but it’s also linked to improvements in access and care quality, said Ateev Mehrotra, professor of healthcare policy and medicine at Harvard Medical School.

But providers should be paid less for virtual services, he added. Medicare payments are based on the time it takes to provide care and the associated space, staff and equipment — so virtual care should cost less and be reimbursed at lower levels.

Plus, payment parity with in-person services could encourage providers to give up their physician practices, or give an unfair advantage to telehealth companies that only offer virtual care. 

Still, offering telehealth doesn’t mean other overhead costs go away, said Eve Cunningham, group vice president and chief of virtual care and digital health at health system Providence. And it takes resources to set up and manage a virtual care program. 

Underpaying could create the wrong incentives, too, said Rep. Larry Bucshon, R-Ind.

“We cannot pay substantially less for telehealth services. There’s balance here, because that will discourage providers from offering them at all,” he said. 

Questions about quality

Lawmakers also raised questions about what types of care are best suited for telehealth services.

“As a community pediatrician, I need a height, a weight, a growth chart, I need blood pressures, I need that pre-work before I walk into the office,” said Rep. Kim Schrier, D-Wash. “I’m just wondering how many diagnoses have been missed because you didn’t see a mole on the skin or curve in the back or falling off on a growth curve?”

When patients returned to physician’s offices after the pandemic eased, providers may have found new symptoms after a physicial exam, said Lee Schwamm, senior vice president and chief digital health officer at the Yale New Haven Health System. But many people simply aren’t able to access care at all, an area where telehealth could help.

“Yes, we might miss some things, but in comparison to what? In comparison to perfect in-person care, sure. But in comparison to reality, I think we’re more likely to pick up signs and symptoms, because we’re actually interacting with the person,” he said.

Another quality concern is care offered by telehealth-only companies, Harvard’s Mehrotra said. In written testimony, he cited one startup, mental healthcare provider Cerebral, that was accused of overprescribing prescription stimulants, arguing there’s a shortage of data on telehealth-only companies’ impact on quality.

Preserving access to in-person care

Medicare beneficiaries also still need to be able to access in-person options if they prefer, witnesses and lawmakers said. 

To ensure in-person access for beneficiaries, telehealth providers should not be allowed to meet network adequacy rules for Medicare Advantage plans, said Fred Riccardi, president of the nonprofit Medicare Rights Center. Now that more than half of eligible beneficiaries are enrolled in the private MA plans, telehealth companies shouldn’t be able to meet those standards and inadvertently erode in-person access, he said.

“It’s important that we preserve patient choice and that Medicare beneficiaries continue to have access to high quality in-person care and robust consumer protections, including network adequacy standards,” said Rep. Frank Pallone, D-N.J.

Congress needs to take action soon to reduce uncertainty for providers, witnesses said. 

Patients expect this model of care now, and providers need permanent solutions to justify the funds needed to support telehealth, Providence’s Cunningham said. 

“When there’s uncertainty in the reimbursement model, and they’re kicking the can down the road one year, the next year, there’s a hesitancy, especially from these smaller practices, to really go all-in because there’s an investment involved in making that transition,” she said. “They need to have that reassurance that reimbursement is going to be stable.”