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WASHINGTON -- Congress should make permanent some of the changes in telehealth policy that were enacted to deal with the COVID-19 pandemic, Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor & Pensions Committee, said Wednesday.

Of the 31 temporary changes in federal telehealth policy made due to the pandemic, three are particularly important, Alexander said: allowing physician reimbursement for telehealth regardless of the patient's location or "originating site" -- including for patients who are at home; allowing Medicare and Medicaid to reimburse providers for nearly twice as many types of telehealth services as before, including emergency department visits, initial nursing facility visits and discharges, and therapy services; and allowing doctors to conduct appointments using common apps like FaceTime or texting, or even visits via landline phone, which required relaxing federal privacy and security rules from the Health Insurance Portability and Accountability Act (HIPAA).

"My instinct is that the originating site rule change and the expansion of covered telehealth services change should be made permanent," Alexander said. "One purpose of this hearing is to hear from the experts and discuss whether there may be unintended consequences, positive or negative, if Congress were to do that." On the other hand, he added, "the question of whether to extend the HIPAA privacy waivers should be considered carefully. There are privacy and security concerns about the use of personal medical information by technology platform companies, as well as concerns about criminals hacking into these platforms."

Telehealth for Vulnerable Populations

Alexander also addressed the question of allowing telehealth physicians to practice across state lines. "There are obvious benefits to allowing healthcare providers to serve patients across state lines during a public health crisis," he said. "As a former governor, I am reluctant to override state decisions, but it may be possible to encourage further participation in interstate compacts or reciprocity agreements."

While everyone at the hearing expressed support for telehealth, each senator had a particular area of interest. Sen. Bob Casey (D-Pa.) said he was concerned about Americans who are particularly vulnerable to COVID-19, including children, seniors, people with disabilities, LGBTQ people, those with mental health or substance use disorders, and the homeless. He asked what could be done to bring telemedicine services to them.

"Without question, vulnerable populations see the benefits of telemedicine services," said witness Karen Rheuban, MD, director of the University of Virginia's Karen S. Rheuban Center for Telehealth in Charlottesville. "We can monitor vital signs, blood pressure, heart failure, and many clinical conditions that would otherwise require in-person visits; therefore we can lower the cost of care and improve outcomes."

Joseph Kvedar, MD, president of the American Telemedicine Association and a professor at Harvard Medical School in Boston, said that reimbursement for telephone encounters "was really helpful in crossing the digital divide during the pandemic. There's a lot we can do by telephone. For instance, as a dermatologist, patients send images of lesions or rashes over our patient portal, and I am able to converse by telephone and conduct care perfectly well." He noted that of 605,000 virtual visits during the last 3 months at the two hospitals he works in, about 60% were by telephone. "We should continue that level of reimbursement if for no other reason than to address this underserved population."

Reimbursement for Non-Physician Providers

Sen. Susan Collins (R-Maine) recounted the experience of a speech and language pathologist in her state who has only recently been able to bill Medicare for telehealth, under temporary waivers issued during the COVID crisis for non-physician providers.

"Do you support continuing these waivers so that non-physician providers can be reimbursed for their telehealth services?" she asked the witnesses. Yes, they all said; and Andrea Willis, MD, MPH, senior vice president and chief medical officer at BlueCross BlueShield of Tennessee, in Chattanooga, said she was looking forward to seeing "best practices" from Medicare on this type of reimbursement.

Sen. Bill Cassidy, MD (R-La.), noted that while physicians might argue that telehealth visits should be reimbursed at the same amount as in-person visits, the overhead cost for a telehealth visit is much lower in terms of personnel, although there are some fixed costs from the initial investment to consider. Willis said the Tennessee Blues plan "did pay parity going into this; we didn't feel we could have that kind of conversation in a crisis situation. We aren't in a rush to abandon that, but we are looking at the data to make sure we see the efficiencies we think we're going to see, and what we don't want to do is to inject additional costs into the system."

Sen. Pat Roberts (R-Kansas) asked about the use of audio-only visits via telephone. Rheuban said she "would be in support of continuation of coverage via audio only," noting that in her pediatric cardiology practice, about a third of her practice's telemedicine visits have been conducted by audio only. "It's an important tool, particularly for more vulnerable populations who don't have access to broadband." Sanjeev Arora, MD, founder and director of Project ECHO, a telehealth project in New Mexico, agreed. "A phone visit is not as good as a video visit, but we don't want the perfect to be the enemy of the good," he said. "A lot of good work can be done by telephone -- as a physician, 80% of all the information I need comes historically, and only a minority comes from the physical exam."

Use in Remote Monitoring

Sen. Doug Jones (D-Ala.) emphasized the value of remote monitoring for people with chronic conditions; Jones has introduced a bill, co-sponsored by Sen. Martha McSally (R-Ariz.), known as the ; it would provide additional funding for providers and health systems in rural America to invest in remote monitoring.

Kvedar agreed that remote monitoring is "a fabulous tool.... It has led to, in conditions like congestive heart failure, savings in terms of keeping people out of the hospital, and keeping them healthy in their home." He added that "in the last 2 years, Medicare has been on board to reimburse for those activities, likewise with monitoring for hypertension -- there's a set of codes to reimburse for that now. Any way you can encourage our colleagues in the private payer space to come on board to support those codes would be a wonderful thing."

Jones asked Willis, whose company also runs a Medicaid managed care plan, what Congress could do to encourage that in private plans. "We have supported that in our Medicaid population," Willis replied. "We're looking at lessons learned to see how we can apply it in the commercial space as well."

The movement to telehealth visits constitutes a big change in healthcare, Alexander said. "In 2016, there were almost 884 million visits nationwide between patients and physicians, according to the CDC." If, as some analysts predict, he continued, "15% to 20% of those were to become remote permanently due to telehealth expansion during COVID-19, that would produce a massive change in our healthcare system. Our job should be to ensure that change is done with the goals of better outcomes and better patient experiences at a lower cost."

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