A welcome document has emerged from the White House, designed to make permanent the silver linings of COVID-19’s dark cloud.
President Trump’s August 3rd “Executive Order on Improving Rural Health” aims to enshrine and expand changes in healthcare laws and regulations adopted amid the pandemic. This order focuses on telehealth and rural care.
In a desperate race to slow and modulate the contagion’s deadly rage, federal and state governments heaved a century’s worth of obstructions over the railings in pell-mell fashion.
States have abandoned certificate-of-need laws that hampered the ability of hospitals and others to increase the supply of care. States have supplemented the beleaguered physician workforce by allowing non-physicians (e.g., nurse practitioners) greater autonomy and capacity to practice up to the full extent of their training.
Many states have shown greater willingness to welcome services performed by healthcare professionals licensed in other states — both for in-person and telehealth appointments. This effective erasure of state lines has made it easier for states to ramp up their resources during times of stress and ramp them down when the crisis passes.
The federal government expanded the circumstances in which physicians can be reimbursed for remote care.
The president’s order recognizes the frailty of healthcare delivery in rural areas, the added stress of the COVID-19 pandemic, and the extent to which telehealth has shored up healthcare in rural areas — and elsewhere.
It notes the mammoth increase in telehealth usage during the pandemic and reflects a desire to make telehealth a permanent and popular fixture of care. Secretary of Health and Human Services Alex Azar just announce plans in three areas within 30 days of the order:
First, he must announce a new model to test innovative payment models. One reason for the slow pre-COVID uptake in telemedicine was that often, doctors could only be reimbursed for in-office visits. In March, Congress and the president took steps to waive restrictions on telehealth services for Medicare beneficiaries.
Second, he must work with the Federal Communications Commission and other agencies toward a strategy for improving rural telecommunications. Many rural areas lack hospitals and other healthcare resources. Hundreds of counties across the United States have zero physicians. These are areas where telehealth services are more desperately needed, yet these same areas often have the poorest access to the cellular signals required for telehealth.
Third, he must recommend initiatives to eliminate regulations obstructing the supply of clinical professionals. This will very likely include expanded scope of practice for nurse practitioners, pharmacists, clinical nurse specialists, physician assistants, certified nurse-midwives and other non-physician professionals — along with their capacity to employ telehealth technologies.
Also, within 60 days, Azar must review temporary measures deployed in the fight against COVID-19 and consider ways to make them permanent.
The growth of telehealth over these months is astonishing. As the executive order notes, Medicare beneficiaries had approximately 14,000 telehealth visits per week — but by late April, that number had expanded to 1.7 million per week. As of that date, 43.5 percent of Medicare fee-for-service primary care visits were conducted remotely.
Telehealth, eyed suspiciously by many physicians pre-COVID, is suddenly a familiar component of American healthcare. In June, the American College of Physicians asked that some of the emergency telehealth measures be made permanent.
The Trump administration would do well to grant broad flexibility in payment models. For example, a requirement that telehealth visits cost the same as in-person visits might be unduly restrictive.
On the one hand, such a policy is good in that it permanently formalizes compensation for telemedicine. On the other hand, rigid payment parity would prevent telehealth providers from offering visits for lower cost than in-person visits. This could waste one of telehealth’s natural advantages — lower overhead costs.
Centers for Medicare and Medicaid Services Administrator Seema Verma said in a statement, “Telemedicine can never fully replace in-person care, but it can complement and enhance in-person care by furnishing one more powerful clinical tool to increase access and choices for America’s seniors.”
If properly incorporated into care options, we will likely arrive at a recognition that “in-person care can never fully replace telemedicine.”
And this sentiment won’t be limited to rural areas.