Telemedicine became increasingly popular for patients and providers during the pandemic. But the state emergency orders, which included waivers for out-of-state medical licenses, that allowed it to flourish are now expiring—leaving many patients without access to important virtual care.
According to the Washington Post, many doctors and patients transitioned to telemedicine during the early months of the pandemic, in part due to state emergency orders that mandated the coverage of telehealth visits and waived requirements for out-of-state medical licenses.
By April 2020, telehealth made up 32% of office and outpatient visits. Since then, usage has stabilized at 13% to 17% across all specialties, according to a report from McKinsey. Overall, telehealth visits greatly increased during the pandemic, with UnitedHealth Group (UHG) covering 34 million telehealth visits in 2020 compared to a mere 1.2 million visits in 2019. (Daily Briefing is published by Advisory Board, a division of Optum, which is a wholly owned subsidiary of UHG.)
In addition, telemedicine allowed patients to get care from other states that would not have been possible before.
For example, Pashtoon Kasi, a medical oncologist at the University of Iowa, said clinical trial enrollment for his field, which can offer patients new treatments they would otherwise not be able to try, reached an all-time high in 2020 due to telemedicine.
"A lot of patients don't have the time or the money to fly down from New York or Florida to come see me in Iowa and discuss if they are a good fit for our trials," Kasi said. "And while they're busy taking time off and taking two flights to get here, their cancer isn't taking a vacation for them to figure this all out."
Separately, Megan McKnight, a PA at Johns Hopkins Bayview Medical Center who helps treat patients with complex gastrointestinal motility disorders, said telemedicine helped her build a rapport with patients who have a history of anxiety or trauma.
"When they're in the comfort of their own homes, they're in their element, so it's easier for them to focus on telling us exactly what they want to tell us,” McKnight said. "Patients who are more anxious in person seem to be more calm on video."
Although many people believed telemedicine would continue to be a staple service even after the pandemic, many of the state emergency orders that originally allowed it to flourish are expiring—which means that many patients will no longer be able to access care virtually, according to the Post.
For instance, Johns Hopkins Medicine in Baltimore had to inform more than 1,000 patients in Virginia that their telehealth appointments were "no longer feasible" after Virginia's emergency orders expired, Brian Hasselfield, medical director of digital health and telemedicine at Johns Hopkins, said.
According to Kaiser Health News, the rollbacks of emergency orders are part of a larger debate over states' authority around medical licensing. Currently, at least 17 states still have emergency orders, including waivers for out-of-state medical licenses, in effect, according to information from the Alliance for Connected Care.
According to KHN, providers have long been divided on whether to change cross-state licensing rules. The different requirements and fees in each state have made it difficult and expensive for providers to get licensed in multiple states. Nonetheless, some clinicians have pushed back against loosening the current rules, worried that the added competition could lead them to lose patients or their jobs.
Barak Richman, a law professor at Duke University, said the challenge to cross-state licensing is "ensur[ing] maximum access to health [care] while assuring quality."
State medical boards argue that it is advantageous to keep local officials in charge. The boards ensure that all applicants meet educational requirements and pass background checks. They also investigate complaints from patients to better ensure patient safety.
"It's closer to home,” Lisa Robin, chief advocacy officer at the Federation of State Medical Boards, said. "There's a remedy for residents of the state with their own state officials."
This sentiment is also endorsed by the American Medical Association (AMA), KHN reports. According to former AMA president Jack Resneck, changes to the licensing rules that don't allow for a centralized authority in a patient's home state would lead to "serious enforcement issues as states do not have interstate policing authority and cannot investigate incidents that happen in another state."
However, other stakeholders who want more flexibility in cross-state licensing rules argue that it can be done safely.
For example, the Department of Veterans Affairs (VA) allows medical providers who are licensed in at least one state to treat patients in any VA facility.
In addition, some states have already entered voluntary interstate compacts that allow state boards to retain their authority while allowing medical professionals to practice in other states more easily. According to KHN, several compacts already exist for nurses, doctors, physical therapists, and psychologists.
One such compact is the Interstate Physician Licensure Compact, which has been enacted by 33 states, the District of Columbia, and Guam. Under the compact, physicians can apply for licenses in different states more easily, although they still have to pay for the cost of a license in each state. Since its inception in 2017, the compact has issued more than 21,000 medical licenses.
According to KHN, similar interstate compacts—especially if they are further supported by federal legislation—could help ensure telemedicine continues to be used and expand access to medical care across the country.
"What's at stake if we get this right," Richman said, "is making sure we have an innovative marketplace that fully uses virtual technology and a regulatory system that encourages competition and quality." (Pasricha, Washington Post, 9/4; Appleby, Kaiser Health News, 8/31)
By John League, Managing Director
Covid-19 demonstrated that location-agnostic care, especially through telehealth, is a solution to numerous care delivery challenges. But unfortunately, we are no longer speculating about what will happen once pandemic workarounds surrounding telemedicine are rolled back. Time's run out—we are experiencing rollbacks now and, as these news stories highlight, it is harming patients and their care. It's time for organizations who recognize benefits to patients from the use of telehealth to take an active role regarding the expiration of pandemic flexibilities. We shouldn't preserve every stopgap measure, but why would we throw the baby out with the bathwater?
Our current health care system has a structure fragmentation regarding telehealth. The pandemic allowed us to try telehealth at a massive scale, and we have paid dearly for that perspective. I believe that everyone should advocate for patients' continued access to telehealth services. Here are four key insights to keep top of mind now and moving forward:
Clinicians, health systems, health plans, and technology vendors are all critical to the role of telehealth. Failing to effectively intersect the various stakeholders and their objectives can lead to silos that dampen the ability to succeed in a telehealth strategy. Recognize the shared goals among each stakeholder and work to join forces for larger success.
Barriers are likely to be structural, which means that no individual stakeholder can solve them on their own. Among the barriers of reimbursement, data, culture, digital literacy, and more, there is one that is crucial now—regulation. State and federal regulations were already limiting, variable, and confusing prior to the pandemic. Now, they are changing as the days go on.
Overcoming these barriers requires multiple stakeholder groups converging to build a shared infrastructure in which telehealth can operate effectively. This includes a shared structure for data capture and exchange, a shared regulatory structure to ensure equitable access, and a shared reimbursement structure to incentivize appropriate use. This will require compromise and tradeoffs—no one is going to get everything they want. The biggest risk is that if no one agrees to give up anything, no one will get anything from telehealth.
Telehealth needs to become systemically integrated into care delivery. We are at an inflection point with widely changing regulations, so it makes sense why leaders may be thinking primarily about legislation, regulation, and funding. But do not forget about the broader set of activities that influence when and how telehealth happens. Activities such as guiding patients to telehealth, clinical research and guidelines, data aggregation, advocacy, and tech innovation all play a role here, and there is a real chance for cross-industry collaboration to solidify the building blocks of the infrastructure required to optimize telehealth.
Every organization functions differently and has different goals for telehealth. Determining what role your organization is best positioned to play requires considering a broad range of advantages and disadvantages, which include things like funding, data, influence, bandwidth, expertise, relationships, buying power, non-monetary assets, or other capabilities. Our industry must work together to fill in the gaps. For example, some organizations may be well-positioned to advocate for legislation that supports broadband access, others may be better positioned to support digital literacy campaigns.
Ultimately, the success of telehealth programs often depends on the reimbursement and regulatory environments in which they operate. Federal and state policies govern how virtual care can be delivered and reimbursed, and overly restrictive regulations can substantially reduce the feasibility and impact of telehealth services—exactly what we saw prior to the pandemic and what we are seeing now with rollbacks. By advocating for more supportive legislation, provider organizations can actively shape telehealth policy development in their favor. For help with how to change the policy landscape in your state, check out our advocacy toolkit that includes step-by-step guidance on identifying policy targets, building an advocacy network, and working with local legislators.
Andrew Mohama contributed to this article.
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