Don’t Let Medicare Beneficiaries Fall Off the Telehealth Cliff

The think tank I work with, the Bipartisan Policy Center (BPC), began an extensive effort a year and a half ago to develop evidence-based policy recommendations for the effective use of telehealth beyond the federal COVID-19 public health emergency (PHE). Once the pandemic took hold in 2020, Congress and the Trump administration greatly expanded telehealth services for Medicare beneficiaries and tied these flexibilities to the PHE. Although the Biden administration just extended the PHE for another 90 days, the declaration will eventually be lifted. Prior to this, Congress extended telehealth flexibilities an additional 151 days post-PHE, but after 5 months, beneficiaries will experience a dramatic benefit cliff if no further action is taken.

We set out to answer whether Medicare beneficiaries will be interested in using telehealth after COVID-19 is no longer an imminent threat to their health and safety. If the answer was yes, we then needed to understand the impact of telehealth utilization on access, future healthcare costs, quality of care, and patient outcomes.

Answering these questions included a multi-step process including a robust literature review, stakeholder interviews, consumer polling, and the assembly of a Digital Health Advisory Group of experts to help guide our policy recommendations. We also conducted our own Medicare data analysis of telehealth utilization before and during the pandemic.

What did we learn?

If certain policies are extended by Congress and the Biden administration, sustained interest in telehealth will likely endure far beyond the pandemic at levels much higher than pre-pandemic.

For Medicare, and other major commercial payers, telehealth utilization remained anemic at less than 1% of outpatient claims in 2019. At the peak of the pandemic however, telehealth use exploded, and in 2020, 44% of Medicare beneficiaries had at least one telehealth visit. By 2021, Medicare beneficiaries’ telehealth use leveled off but remained almost 40 times higher than pre-pandemic levels.

Interestingly, our data analysis showed that Medicare beneficiaries with disabilities, end-stage renal disease, multiple chronic conditions, and those eligible for both Medicare and Medicaid were much more likely to use telehealth services in 2021. Also, people in urban areas used telehealth at higher rates than their rural counterparts — essentially the further from urban centers people lived, the less likely they were to use telehealth services, suggesting that access to high-speed internet remains a barrier in rural America. Minorities (Black, Hispanic, Asian American, Native American) were more likely to use telehealth than white, non-Hispanics, which suggests that people of color may be using telehealth to overcome barriers to in-person care, such as lack of transportation or less work flexibility.

In this post-pandemic new normal, a lot of telehealth was for primary care.

Before the pandemic, telehealth was largely for people living in rural areas to get access to specialty care, and that is precisely how pre-pandemic telehealth policy was restricted: Before the pandemic, patients were required to travel to designated sites to receive telehealth and could not do appointments from home as they do today. Now, with all the policy constraints removed, primary care makes up the largest share of telehealth visits in Medicare — almost 40% of all telehealth visits were for primary care services in 2021. Surprisingly, 95% of those primary care visits were in the context of established patient-provider relationships. In other words, the vast majority of Medicare beneficiaries sought tele-primary care services from providers they had already seen before, likely in-person.

We observed a high reliance on telehealth for new behavioral health visits.

In 2021, 44% of all behavioral health services delivered to Medicare beneficiaries occurred via telehealth. The majority of those visits (65%) were delivered through new treatment relationships. In other words, many Medicare beneficiaries newly accessed mental health and substance use treatment via telehealth. Access to tele-behavioral health services can address the lack of behavioral health providers and help patients overcome the stigma related with these services, especially in rural, tight knit communities. In 2021, more than one-third of Americans (37%) lived in areas experiencing shortages of mental health professionals. Without access to telehealth, many beneficiaries may lack the ability to see a behavioral health provider. Additionally, there is ample research to show that videoconferencing is largely of comparable quality to treatment delivered in person for mental health visits.

A few red flags have emerged and must be addressed as telehealth use continues.

During this temporary extension of the benefit, very few guardrails have been placed on telehealth, and rightly so. Congress and the administration were focused on keeping access to care as intact as possible amid stay-at-home orders and public fears about contracting COVID-19. However, several concerning trends have emerged. For one, some venture-backed startups may be taking advantage of looser pandemic rules to prescribe medications such as Adderall and ketamine to consumers. In fact, last month, the U.S. Drug Enforcement Administration announced they are investigating certain mental health startups for reports of prescribing abuses.

Another area that merits further caution is telehealth delivered over the phone (also known as audio-only telehealth). This modality is largely new since the COVID-19 pandemic, yet almost 1 out of every 5 telehealth visits for Medicare beneficiaries were by phone in 2021. Providers used to call their patients with lab or test results before the pandemic and these interactions were not billed for individually outside of the office visit; however, now, these interactions can be billed separately as audio-only telehealth. While this modality may serve as a lifeline for older, rural, poorer, and minority populations who are disproportionately affected by barriers to accessing telehealth services, we don’t yet fully understand the quality of these services or the impact they will have on healthcare spending.

Our key recommendations include:

  • Congress and the Biden administration should extend most telehealth flexibilities for Medicare beneficiaries for an additional 2 years beyond the PHE so studies on the impacts on access, healthcare costs, quality, and outcomes can continue.
  • Congress should repeal in-person visit requirements for tele-mental health services given the effectiveness of these services, Americans’ increased need for mental health treatment, and the lack of access to behavioral health providers nationally, especially in rural America.
  • For most patients, CMS should require an in-person examination before providers can prescribe opiate pain medications, or other substances determined prone to abuse. This requirement should not apply to the treatment of opioid use disorder.
  • CMS should limit audio-only visits to established patient-provider relationships. For specialty care, audio-only services should be limited to those who either live in rural America or have a valid need for telephone visits (e.g., those who lack broadband access or the necessary devices for video visits).

Our complete findings and recommendations are available in our report, The Future of Telehealth After COVID-19: New Opportunities and Challenges. We remain excited about telehealth’s potential and our continued work in this area.

Julia Harris, MPH, MIA, is a senior policy analyst at the Bipartisan Policy Center.

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