The new executive order lays out a lot of goals for telehealth and rural health care—and not a lot of details. Emphasis on addressing the shortage of clinicians in rural areas is welcome, and potential infrastructure investments to support rural health care and broadband access are essential and overdue.
But what stands out about the executive order is what it does not directly address: reimbursement and licensing. The ultimate resolution of these issues will require Congress to act, especially on licensing. For now, however, we can read the executive order for clues about how overall federal health care objectives might require or benefit from expanded use of telehealth.
Reimbursement. The executive order reinforces previous comments by CMS administrator Seema Verma about the need to assess which flexibilities and services offered during the public health emergency (PHE) should continue permanently—for all patients, not just those in rural areas. However, the executive order takes no position on most providers' biggest concern about telehealth: reimbursement. And while Verma has consistently indicated that CMS will make broader use of telehealth for Medicare beneficiaries, she has also stated that she does not see reimbursement for telehealth and in-person visits as a "one-to-one" relationship.
The executive order calls for HHS to develop a new "innovative payment model" for rural providers aimed at pushing providers toward value-based care. The language in the order is suggestive of a capitated model that would offer "predictable financial payments" to providers, and it states that such a model should offer flexibilities from existing Medicare limitations. However, while telehealth would be an essential component of any such model, no specific services, modalities, or payment mechanisms are indicated.
What to expect: Other new-in-kind arrangements between payers and providers around telehealth. Even if reimbursement parity is not an option, such arrangements could help maximize the value of telehealth across the care continuum.
Licensing. Cross-state clinician licensure is a significant obstacle to expanding access to care through telehealth. The executive order touches obliquely on these issues in its mandate for HHS to offer proposals to "increase rural access by eliminating regulatory burdens that limit the availability of clinical professionals" and to evaluate "the services, reporting, staffing, and supervision flexibilities offered to Medicare providers in rural areas."
Ultimately, however, Congress will have to address this issue through legislation. And while bipartisan legislation has been proposed to allow national licensing reciprocity during a PHE, it doesn't address any permanent changes.
What to expect: Continued emphasis on state-level compacts and reciprocity. States have been faster to enact legislation to broaden the use of telehealth, and there are already existing frameworks, compacts, and multi-state boards to support cross-state licensing. Still, the prevailing patchwork of state-level licensing simply does not align with the needs of an industry that relies on telehealth as an essential mode of care delivery.