Telehealth has blown up amidst the COVID-19 crisis and along with it have come a wave of legal and regulatory changes and relaxations. Which of these changes will remain, and will telehealth adoption, as we know it during COVID-19, last past the pandemic? I am pulling out my crystal ball and making predictions on which changes will be permanent and which ones will be rolled back to the previous status quo.
Telehealth HIPAA Enforcement Discretion
As you probably know, the Office for Civil Rights (OCR), which is tasked with enforcement of HIPAA, issued an “enforcement discretion” for telehealth during the COVID-19 national emergency. This allowed for non-public facing video communication applications (i.e., FaceTime, Facebook Messenger, Google Hangouts, Skype, etc.) to be used for telehealth. Although, they did also encourage healthcare organizations to use HIPAA compliant applications.
This is an easy prediction for me. Given the encouragement to use existing HIPAA-compliant video applications, I think this enforcement discretion will end at the end of the pandemic. I might feel different if there weren’t HIPAA-compliant options available, but given there are HIPAA-compliant solutions that accomplish the same thing in a more secure manner and no major loss of usability, get ready for this one to roll back. Consumer video apps make sense in a pandemic but aren’t necessary outside of it.
This is a little harder area to predict, but first let us highlight what has changed. Medicare has expanded reimbursement for telehealth video visits and essentially created payment parity between a telehealth video visit and an in-person visit. Second, they have allowed reimbursement for voice-only visits at a similar rate to a video visit. Third, they have expanded where a visit can be done and still qualify for location-specific reimbursement. There are several other nuances, but these are the three major changes in my view.
Here are my predictions:
Payment parity for video visits versus in person visits will remain, including the types of visits that will be reimbursed.
Voice visits will be evaluated and scrutinized by the government. They will ultimately allow them in extremely specific cases where other options are not available. I hope I am wrong on this one and there are legislative efforts to ensure that this remains and even expands. However, I think we are still years from CMS figuring out how to reimburse based on what was accomplished by the encounter whether in person, on video, over the phone, or via text.
CMS will go back to location specific reimbursement with a few minor exceptions.
Telehealth Medical Licensure
Another major change was Medicare and Medicaid allowing doctors to practice across state lines and most states following suit. I predict that Medicare and Medicaid will find a way to leave this waiver in place. However, it is important to note that doing so does not solve the state medical licensure laws. I predict we will have a hodgepodge of state actions that will be a mess to navigate with half of states rolling back to their previous laws and the other half still allowing doctors to practice across state lines. I would like to predict that national legislation is on its way to make national medical licensure a reality, but I am not ready to bet on that happening given the current state of government affairs.
While we have seen mass adoption of telehealth, the problem is that most of it was essentially forced adoption. Healthcare organizations were largely faced with practicing telehealth or not seeing patients. COVID-19 changed the telehealth value equation dramatically. Will that last past the pandemic?
I predict that one-third of smaller medical practices will go back to their old habits and mostly see patients for in-person visits. One-third of these practices will use telehealth in very targeted situations and for a certain subset of visits that are well defined. One-third will embrace telehealth as a viable alternative and will largely yield to the patient’s preference when seeing them in-person or virtually.
When it comes to larger healthcare organizations and health systems, I expect most will embrace telehealth and find a way to integrate it into their offering as they compete with direct to consumer telehealth companies. Large healthcare organizations will use their scale to allow some of their doctors to just do in person visits while having other doctors be purely telehealth. They will create committees that evaluate which specialties, appointment types, and patients are a good fit for telehealth and which are not, and they’ll design systems to be able to route patients based on these decisions.
I predict that telehealth satisfaction will be based on how well the telehealth vendor together with the healthcare organization define the workflow. Many will do this poorly and get a lot of kickback from both their clinicians and their patients. However, those that invest in a seamless workflow for both their clinicians and their patients will result in high satisfaction from both groups.
Mixed Patient Reaction
While I would love to see a dominant patient reaction that requires a telehealth option, I predict we will see a mixed reaction from patients. Many will love the telehealth experience and will not be able to imagine going back to an in-person visit while others will be ready to head back to the office for the face-to-face encounter and physical exam. As such, those who want to push telehealth will find advocates for it and those who want to return to in-person visits will find those voices as well.
Commercial Payers Response to Telehealth
I am not making any predictions on how commercial payers will respond to telehealth long term. It is not clear to me what they are thinking and whether they will fully embrace telehealth or not. It feels like they should in this environment, but many of them profit from the inefficiencies of the old system.
Other Things to Watch
I am also going to be watching how direct-to-consumer telehealth companies impacts the market. If everyone is starting to offer telehealth visits, then what is the reason that a patient would be seen by their PCP versus a direct-to-consumer telehealth provider. Certainly, the former would argue that they have an ongoing relationship to the patient, but that is not true for many patients who do not have a PCP they see regularly. Plus, the direct-to-consumer telehealth companies can create a streamlined patient experience that will be hard for healthcare organizations to match. Will patients value an ongoing relationship or convenience more?
Plus, how long will social distancing be with us? Will the fear of going to the doctor’s office lead many to seek out telehealth for a long time to come or will that fear subside relatively quickly? This one is hard to predict since much of the science around COVID-19 is still being worked on. However, it is safe to say that some portion of the population already had this fear pre-COVID-19 and more will likely have it going forward even once vaccinations, treatments, and antibody testing are more fully understood.
While I do think telehealth is here to stay, there are still a lot of factors that could impact to what extent we do telehealth going forward. I think many who are on the telehealth bandwagon underestimate the power of going to back to “how we have always done it.” If you want to keep your eyes on the biggest predictor of telehealth success: follow the money. Telehealth reimbursement is going to be the key influencer of how much telehealth remains post COVID-19.
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